Columbia  3Untoergitp 

intljeCttpirflfomgnrk 

College  of  ijSfjpsiictang  anb  burgeons 

Hibrarp 


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ON 


CONGENITAL     DISLOCATIONS 


HEAD    OF    THE    FEMUR. 


TREATISE 


ETIOLOGY,   PATHOLOGY,  AND   TREATMENT 


CONGENITAL    DISLOCATIONS 


HEAD  OF  THE  FEMUR. 


ILLUSTRATED   WITH   PLATES. 


BY 


JOHN    MURRAY    CARNOCHAN,    M.D.. 

LECTURER    ON    OPERATIVE    SURGERY    WITH     SURGICAL    AND    PATHOLOGICAL    ANATOMY, 

&C  ,   &C. 


.  .  .  .  "mon  but  n'a  point  ete  lie  grossil  le  catalogue  dcja  trop  nuinbreux  des  niiseres 
humaines,  mais  d'eviter  am  practiciens  de  graves  erreurs  de  jugement.  ei  atu  malades,  des 
traitemena  aussi  iautiles  qu'ils  sont  dangereux."— Ddpuytrkn— CWjujim  Chirurgicalc. 


NEW     YORK: 

S.    S.    &    W.    WOOD,    261    PEARL   STREET 


MDCCCL, 


?2> 


Entered,  according  to  Act  of  Congress,  in  the  year  1850,  by 

JOHN  MURRAY  CARNOCHAN. 

in  the  Clerk's  Offioe  of  the  District  Couit  of  the  Southern  District  of  New  York. 


CONTENTS 


PARE 

Preface via 

Chap.    I. — General   Observations 11 

II. — Anatomical  Remarks 35 

III. — Etiology   ...........  46 

IV. — Symptomatology        .........  91 

V. — Diagnosis  .         .         .         .         .         .         .         .         .         .131 

VI.— Prognosis 139 

VII.— Pathology 147 

VIII. — Treatment '-215 


PREFACE. 


Science  is  progressive,  and  it  is  necessary  to  keep  pace  with 
its  rapid  advancement. 

The  department  of  Surgery  occupies  an  extensive  domain  ; 
its  beneficial  influence  upon  mankind  is  universally'  acknow- 
ledged, and  its  professors  now  hold  a  prominent  rank  in  the 
great  intellectual  arena  of  the  world. 

The  more  correct  and  definite  knowledge  derived,  in  more 
modern  times,  from  a  better  directed  and  closer  study  of  Ana- 
tomy, Physiology,  and  Pathology,  has  led  to  vast  improvements, 
and  given,  among  others,  a  new  impetus  to  what  may  be 
termed  curative  and  conservative  surgery. 

The  progress  of  this  department  of  science,  in  its  intimate 
connection  with  the  great  interests  of  the  human  race,  demands 
of  the  surgeon  of  the  present  day,  not  only  the  ability  of  per- 
forming dexterously  a  complicated  operation,  but  chiefly  a 
profound  knowledge  of  the  various  pathological  conditions  to 
which  the  human  organism  is  liable.  Without  this  knowledge, 
a  correct  discrimination  among  the  various  morbid  afTections 
of  the  body  cannot  be  attained;  the  diagnosis  must  be  uncer- 
tain for  want  of  reliable  data  for  its  basis,  nor  can  remedial 
measures  be  adopted  intelligently  or  judiciously. 

From  the  increased  light  now  shed  upon  Surgical  Pathology, 


Vlll  PREFACE. 

it  is  to  be  hoped  that  the  time  has  gone  by  for  the  recurrence 
of  many  grave  errors  in  practice,  heretofore  committed,  and 
that  we  shall  not  again  hear,  for  instance,  of  opening  an  aneu- 
rism, under  the  supposition  of  merely  giving  exit  to  a  collection 
of  purulent  matter,  or  of  the  application  of  the  ligature  upon  a 
large  arterial  trunk,  for  the  cure  of  aneurism,  where  no  aneu- 
rism existed  ; — the  lamentable  results  of  erroneous  diagnosis. 

Some  few  years  since,  while  in  Europe,  and  availing  myself 
of  the  advantages  at  hand  in  the  Hospitals  and  Surgical  Schools 
of  the  great  foreign  capitals,  I  drew  up  the  outline  of  a  sketch, 
to  be  filled  up  on  my  return  to  the  United  States,  which  should 
embrace  a  general  parallel  between  the  state  of  British  and 
French  Surgery,  and  the  actual  condition  of  the  science  in  our 
own  country.  Other  matters,  however,  claimed  my  attention, 
and  have  prevented  the  immediate  fulfilment  of  my  design. 

There  is  one  point  of  Surgical  Pathology,  however,  previ- 
ously altogether  unnoticed  in  this  country,  upon  which,  among 
other  investigations,  I  bestowed  considerable  attention  while 
abroad,  and  in  relation  to  which  I  contributed  at  times  brief 
articles  to  some  of  the  Medical  Journals  : — I  allude  to  the  Con- 
genital Dislocations  of  the  Head  of  the  Femur  at  the  Ilio- 
femoral articulation. 

Contributions  of  that  kind  being,  however,  necessarily  con- 
fined within  narrow  limits,  and  nothing  having  since  appeared 
on  the  subject  from  other  sources,  in  the  English  language, 
1  have  endeavored  in  the  following  pages,  in  some  measure, 
to  fill  up  the  void  existing  in  relation  to  this  important  point 
of  surgery. 

The  arrangement  I  have  adopted  is  a  simple  one  ;  beginning 
with  the  Etiology,  and   then  passing  on,  successively,  to  the 


PREFACE.  IX 

Symptoms,  the  Diagnosis,  the  Pathology,  and  concluding  with 
the  Remedial  Treatment. 

The  cause  of  this  Displacement  has  given  rise  to  much 
discussion,  and  the  variety  of  opinions  offered  shows  sufficiently 
the  obscurity  of  the  origin  of  this  connate  affection.  I  have 
ventured  to  propose  my  own  opinions  on  this  head,  which, 
I  trust,  are  justly  founded  upon  Anatomy  and  Physiology. 

The  Symptoms  and  Pathology  are  illustrated  by  correct 
delineations,  taken  from  cases,  which  came  under  my  own  obser- 
vation, and  from  dissections,  made  by  myself. 

With  regard  to  the  Treatment,  I  have  recorded  that  course 
which  has  been  attended  with  success,  and  have  also  mentioned 
additional  suggestions  which  have  been  advanced  by  eminent 
authority. 

The  subject  of  the  present  monograph  being  a  novel  one. 
and,  indeed,  quite  new  upon  the  American  continent,  I  may 
claim  some  indulgence  for  any  imperfections  which  may  be 
met  with  in  its  pages,  on  the  ground  of  its  being  the  first 
attempt  to  introduce  to  the  Surgeons  of  this  country  a  systematic 
account  of  this  important  affection  of  the  human  organism. 

498  BROADWAY, 

Dec,  1849. 


I 


(        i 


N°U  • 


EXPLANATION  OF  PLATE    No.  I. 

Antcro-latcr.il  view,  as  presented  during  life,  in  a  case  of  Double  Congenital  Dis- 
location of  the  Head  of  the  Femur  upon  the  Dorsum  of  tho  Ilium. 

a  Anterior  Inferior  Spinous  Process  of  the  Ilium. 

6  Trochanter  Major. 

d  Superior  Margin  of  the  Patella. 

k  Inguinal  Fold. 

g  Region  of  the  Pubes  tilted  downwards  and  backwards. 

/  The  foot  resting  on  the  sole,  the  toes  being  directed  forwards. 


EXPLANATION    OF   PLATE    No.    II. 

Lateral  view  of  the  samo  case  as  the  preceding,  of  Double  Congenital  Dislocation 
of  the  Head  of  tho  Femur  upon  the  Dorsum  of  the  Ilium. 

a  Anterior  Inferior  Spinous  Process  of  the  Ilium. 

b  Trochanter  Major. 

e  Tho  excurvation  in  the  lumbar  region. 

/  The  foot  resting  on  the  ground,  and  directed  forwards,  without  inversion  or  aver- 
sion of  the  toes. 

See  Report  of  this  Case,  Chapter  IV. 


ON 


CONGENITAL    DISLOCATIONS 


HEAD    OF    THE    FEMUR. 


CHAPTER  I. 

GENERAL    OBSERVATIONS  ON  CONGENITAL    DISLOCATIONS  OF 
THE    HEAD    OF    THE    FEMUR. 

The  diseases  and  accidents  occurring  at,  or  in  prox- 
imity to,  the  coxo-femoral  articulation,  are  numerous  and 
complex.  An  intimate  knowledge  of  the  pathology  of 
each  of  them  is  requisite,  in  order  that,  when  circum- 
stances render  an  opinion  necessary,  a  correct  differential 
diagnosis  may  be  formed  in  relation  to  affections  of  this 
portion  of  the  organism.  The  morbid  conditions  of  the 
hip-joint  are  attended  by  peculiar  and  characteristic  symp- 
toms, frequently  accompanied  with  displacement  of  the 
articulating  surfaces,  either  gradual,  from  causes  more  or 
less  prolonged,  or  immediate  and  simultaneous  with 
external    violence;    and   thus,    the    discrimination  of  one 


J 2  GENERAL     OBSERVATIONS    ON    CONGENITAL 

pathologic  state  from  another  might  be  supposed  to  be  free 
from  difficulty  or  embarrassment.  Yet  errors  in  diagnosis 
do  often  occur  in  regard  to  the  real  nature  of  affections  of 
this  region,  and,  as  an  unavoidable  sequent  to  error  of 
judgment,  an  improper  course  of  treatment  is  adopted, 
useless  in  itself,  and  dangerous  in  its  results. 

It  is  somewhat  remarkable  that  those  dislocations 
of  the  hip-joint  which  have  been  denominated  original 
or  congenital,  and  which  are  of  equal  importance  in  a 
scientific  point  of  view  with  the  traumatic  displacements 
of  the  head  of  the  femur,  should  have  been  so  entirely 
overlooked  by  the  surgical  writers  of  England  and  of  this 
country.  The  great  authority  on  the  subject  of  disloca- 
tions, Sir  Astley  Cooper,  in  his  enumeration  of  the  differ- 
ent varieties  of  articular  displacement,  has  not  referred  to 
any  other  luxations  of  the  head  of  the  femur  than  those 
happening  during  the  different  epochs  of  extra-uterine 
existence,  and  resulting  from  external  violence,  from 
relaxation  of  the  ligaments,  from  paralysis  of  the  muscles, 
from  excess  of  the  synovial  secretion,  or  from  strumous 
ulceration  at  the  joint  ,*  and  even  Brodie,  whose  researches 
into  the  pathology  of  the  joints  have  been  so  extensive 
and  erudite,  has  not  made  a  cursory  allusion  to  the  re- 

*  In  the  last  London  edition  of  Sir  Astley  Cooper's  "  Treatise  on  Dislocations," 
muscular  spasm  is  mentioned  as  sometimes  causing  in  certain  individuals  dislocation, 
for  example,  of  the  lower  jaw  ;  and  an  instance  is  alluded  to  where  dislocation  of  the 
second  phalanx  of  the  little  finger  resulted  from  the  shock  of  an  electric  machine, 
but  in  these  eases  he  evidently  has  no  reference  to  intra-uterine  dislocations. 


DISLOCATIONS    OF    THE    HEAD    OF    THE    FEMUR.  13 

markable  dislocation  of  the  femur  of  which  we  are  about 

to  treat,  and  which  has  frequently  been  mistaken  for  oilier 
diseases  of  this  part,  and  especially  for  morbus  coxarius. 

In  examining  the  extensive  collections  in  the  museums 
attached  to  St.  Thomas'  and  Guy's,  and  to  the  other 
hospitals  of  London  and  Great  Britain,  I  was  unable  to 
find  any  specimens  illustrative  of  congenital  dislocation 
of  the  head  of  the  femur;  and  I  may  make  the  same 
remark  in  regard  to  the  pathological  collections  of  this 
country. 

From  this  fact,  and  from  the  silence  of  American  sur- 
gical writers  on  the  subject,  I  have  thought  that  the  fol- 
lowing description  of  the  causes,  symptoms,  and  morbid 
appearances  of  this  dislocation  at  the  hip-joint,  with  the 
accompanying  cases,  and  with  drawings  taken  from  dis- 
sections which  I  have  had  the  opportunity  of  making, 
might  be  deemed  worthy  of  perusal  ;  or,  at  all  events, 
that  they  might  direct  attention  to  a  pathologic  condi- 
tion of  this  joint,  not  generally  understood,  and  which, 
in  the  details  of  surgical  practice,  is  not  unlikely  to  be  met 
with. 

Luxations  differing  in  their  nature  from  those  occurring 
as  the  result  of  traumatic  lesion,  are  alluded  to  by  Hippo- 
crates, but  in  so  vague  a  manner  that  no  definite  conclu- 
sion can  be  drawn  from  his  remarks.  In  his  Book  '  De 
Articulis"*  he  says  that  children   in  the  womb   may  have 

*  Liber  d<-  Articulis.  sect.  3.  sent.  B8  61  94  ;  sect.  4,  Bent    1  61  5. 


14  GENERAL     OBSERVATIONS    ON     CONGENITAL 

their  arms  and  legs  dislocated  by  falls  or  blows,  or  by 
having  been  pressed  upon,  as  is  remarked  in  those  who 
are  born  with  club-foot. 

This  matter  had  fallen  into  oblivion  when  Ambroise 
Pare,  and,  at  a  later  period,  Verduc,  again  pointed  out  the 
existence  of  displacements  occurring  at  the  joints  befoie 
birth,  but  still  in  language  of  much  obscurity  as  regards 
their  real  nature. 

Pare,  in  his  Chapter  on  the  Causes  of  Dislocations, 
thus  expresses  himself : — "Les  causes  des  luxations  sont 
trois  en  general,  a.  scauoir  internes,  et  externes,  et  la 
troisieme  est  Mreditaire. 

"  Internes,  comme  quand  il  y  a  certaines  hutneurs  et  ven- 
tosites  qui  tombent  aux  iointures  en  si  grande  abondance, 
qu'elles  lubrifient  et  relaschent  les  ligaments  qui  lient  les 
os  ensemble  et  les  jettent  hors  de  lew  boette :  ou  bien 
remplissent  lesdits  ligamens,  de  telle  sorte  qu'iceux  engros- 
sis,  et  par  consequent  accourcis,  venans  a  se  retirer  ensem- 
ble, retirent  ou  les  apophyses  des  os,  dont  ils  ont  leur 
origine,  ou  bien  les  os  mesmes  hors  lews  sinus  et  cauite.  .  . 
La  cause  hereditaire  est  celle  qui  vient  de  pere  et  mere 
aux  enfans,  comme  quand  les  bossus  engendrent  des  enfans 
bossus  et  contrefaits,  et  les  boiteux  engendrent  des  boiteux : 
dont  F  experience  fait  foy,  non  pas  tousiours,  mais  le  plus 
souuent."* 


*  Le  Qvatorzieme  Livre  Traitant  des  Luxations.     Chapitre  III  (Edition  by  Mal- 
gaigne). 


DISLOCATIONS    OF    THE     HEAD     OF     I'lli:     I  I. MM;  10 

And  again  in  bis  chapter  "  Da  la  luxation  de  la  hanche,"* 
he  says,  "  xM;iis  es  luxations  faites  de  cause  interne^  elle 
peal  estre  incouiplette,  parce  que  les  muscles  ei  ligamens 
sont  relasches,  et  n'ont  hi  force  i!<'  ramener  ledil  os  en  sa 
iointe,  ou  cauite." 

In  these  passages,  and  particularly  where  I  have  used 
italics,  allusion  to  congenital  luxations  at  the  hip  and  else- 
where may  be  intended,  hut  if  Pare  were  conversant  with 
the  real  nature  of  the  displacement  in  question,  he  does 
not  express  himself  in  explicit  language  in  relation  to  it  ; 
although  it  is  probable  that  the  hints  thrown  out  In  the 
great  French  surgeon  of  the  sixteenth  century  have  been 
made  available  by  some  modern  writers.  In  fact,  one 
recent  writer,  rejecting  other  opinions,  has  assumed  the 
hypothesis  that  the  cause  of  congenital  luxation  at  the  hip 
is  nothing  more  than  a  superabundant  secretion  of  fluid 
into  the  ilio-femoral  articular  cavity. 

A  distinct  and  definite  statement  of  the  existence  of  an 
intra-uterine  dislocation,  takiug  place  before  birth,  at  the 
ilio-femoral  articulation,  appears  to  have  been  made  in 
1812  by  Chaussier,  who  is  reported  to  have  entered  in  the 
note-book  of  the  Hopital  de  la  Maternity  of  Paris  an 
account  of  the  skeleton  of  a  foetus,  in  which  man)  frac- 
tures were  found,  besides  two  congenital  luxations,  one 
situated  at  the  humero-scapular  articulation,  the  other  at 
the  hip  joint;  which  luxations  he  designated  l>\  the  name 
of  spontaneous  (Luxations  Spontam 

■  Le  Civaturzieinc  Livrc.  Cbapitre  XL.  De  la  Luxation  dela  Hanohe. 


10  GENERAL    OBSERVATIONS    ON    CONGENITAL 

Palleta,  an  Italian  surgeon,  practising  in  Milan,  at  the 
commencement  of  the  present  century,  is,  as  far  as  I  can 
learn,  entitled  to  the  credit  of  having  first  given,  in  1820, 
an  intelligent  description  of  the  congenital  dislocation  of 
the  head  of  the  femur  from  the  cotyloid  cavity  ;*  but 
many  years  previously  he  had  indicated  with  considerable 
precision  this  obscure  morbid  condition  of  the  hip-joint  in 
his  work  published  in  1 788,  entitled  "  Adversaria  Chirur- 
gica."  In  the  essay  "  De  Claudications  Congenita"  he 
describes  certain  malformations  at  the  hip-joint,  which 
can  only  be  referred  to  the  class  of  dislocations  at  this 
articulation,  which,  under  the  name  of  congenital,  have 
attracted  the  attention  of  some  modern  French  surgeons. 
It  is  probable,  however,  that,  at  this  early  period  of  his 
labors,  this  author  was  not  well  acquainted  with  all  the 
characteristics  of  the  displacement.  But  from  observa- 
tions on  the  living,  and  dissections  made  of  persons  who 
had  succumbed  to  various  maladies,  he  had  acquired  more 
knowledge  in  regard  to  this  morbid  condition  of  the  hip- 
joint  than  any  of  the  surgical  writers  who  had  preceded 
him.  The  descriptions  which  he  has  left  of  the  symp- 
toms manifesting  themselves  during  different  stages  of  life, 
and  of  the  results  of  the  post-mortem  examinations  which 
he  was  enabled  to  make,  conclusively  siiow  that  the 
Italian  surgeon  was  acquainted  with  the  general  patholo- 
gical facts  appertaining  to  this  affection.     In  his  first  case, 

*  Exercitationes  Patholoaicse. 


DISLOCATIONS    OF    THE    HEAD    OF    THE     FEW  I;.  17 

although  unable  to  verify  it  farther  by  autopsic  examina- 
tion, he  thus  proceeds:  "Puerum  octenticm  claudicantem 
consilii  causa  ad  me  adduxerunt  28  aprilis  ann.  L78U.  .  . 
E rat  cms  sinistrum  sesqui  pollice  hrevius  dextero  ;  genu 
introrsum  non  nihil  conversum,  trochanter  major  ah  heva 
parte  emincntior.  Resupinato  puero  dam  manu  altera 
trochanterem  deprimeham,  altera  cms  et  genu  extendere 
eonabar,  membrom  affectum  par  sano  reddebatur:  sublata 
extensione  idem  membrum  ad  pristinam  brevitatcm  re- 
ducebatur.  Motus  articuli  in  omuem  partem  erat  facilis. 
Causa  cui  quidem  ea  contractio  tribui  poterat,  nulla  prse- 

cesserat   manifesta Quid   eidem   evenerit,   ignoro, 

nunquam  enim  postea  rediit."* 

Although  there  are  symptoms  in  the  above  case  that 
are  common  to  other  affections  at,  or  about,  the  hip-joint, 
as  well  as  to  congenital  luxation  of  the  head  of  the 
femur,  yet  the  age  of  the  patient,  the  lameness — not  being 
referred  to  external  injury, — the  easy  extension  of  the 
limb,  already  shortened  by  half  an  inch,  to  the  length  of 
the  sound  member,  the  immediate  return  to  its  pristine 
shortness  as  soon  as  extension  was  removed,  and  the  free 
motion  of  the  joint,  give,  when  taken  collectively,  a  gene- 
ral character. to  the  malady  described,  which  precludes  the 
supposition  of  its  having  been  the  result  of  strumous  ac- 
tion, or  of  accidental  lesion. 

*  Adversaria  Chirorgicai 


18       GENERAL  OBSERVATIONS  ON  CONGENITAL 

Passing  over  another  case  similar  to  that  just  related, 
and  of  which  also  Palleta  was  prevented  from  making  a 
post-mortem  examination,  we  shall  make  an  abstract  of  a 
case  in  which  he  had  an  opportunity  of  dissecting  the 
various  structures  about  the  joint.  u  Adolescens  tenui  ha- 
bitus vigesimo  aetatis  anno  moritur  ex  capitis  vulnere,  8 
maii  1783.  Gluum  mensae  anatomicae  alium  in  fin  em  im- 
poneretur,  eras  dextri  lateris  contractum  observavimus.  Cal- 
caneum  tribus  transversis  digitis  supra  sinistrum  erat,  genu 
duos ;  trochanter  tuberosior  et  eminentior ;  natis  item  ro- 
tundior  et  globosior,  sulcus  autem  ejus  vix  mutatus  erat  ex- 
cepto  apice,  qui  paulo  incurvus  versus  trochanterem  ten- 
debat.  Caeterum  nee  triceps  coxae  musculus  distentius, 
nee  pes  in  latos  conversus  observabalur  ;  nee  item  alii 
musculi   coxam  ambientes  quidquam  a  naturali  diversum 

habebant.  praeter  matatam  directionem     Capsa 

dein   articulari  incisa, cotyle  sanum   erat, 

profundum,  cardla^ine  sua  obductum.  figura  duutaxat 
matatam.  Caput  femoris  in  vertice  valde  depressum, 
atque  inferius  productum  velut  in  obtusum  rostrum 
terininabat.  Tota  ejus  superficies  cartilagine,  colore. 
et  crassitie  naturali  tegebatur,  excepto  exiguo  tractu  circa 
ligamenti  teretis  foveam,  ubi  sic  attenuata  cernebatur.  at 
diaphana  redderetur.  Ligamentum  teres  infra  capitis  cen- 
trum trochanteri  minori  propius  inserebatur.  Robustum 
tamen  illud  erat,  crassum,  et  lata  triangulari  basi,  ex  coty- 


DISLOCATIONS   OF    THE    HEAD    OF    THE    FEMUR.  19 

lis  sulco  prodibat.  Femoris  colluin  eral  perbreve,  si  eo 
nomine  distinguenda  est  ossea  portio  a  capitis  rostro  in 
transversura  ducta,  atque  in  trochanteric  basiui  inserta. 
Hncc  porro  una  cum  capite  compressa  ab  lateribus,  et  cir- 
cum  eminentiis  parvis  obsita  erat,  circulari  articuli  liga- 
mento  inclusis."* 

The  author  then  proceeds  by  giving  a  detailed  account 
of  the  dimensions  and  measurements  of  the  articulating 
surfaces  of  the  cotyloid  cavity  and  head  of  the  femur,  & 
which  it  is  unnecessary  to  repeat  here.  The  extract  just 
made  is  sufficient  to  point  out  some  of  the  pathological  condi- 
tions peculiar  *o  the  congenital  dislocation  of  the  hip-joint. 

The  next  case,  reported  by  the  Italian  surgeon,  which 
presented  an  opportunity  of  inspecting  the  body  after 
death,  is  also  characteristic  of  this  affection.  It  is  detailed 
as  follows  . — "  Femoris  colluin  eo,  quod  descripsimus, 
modo  vitiari  posse  altera  me  docuit  sectio  in  puella  bimula. 
Hujus  femur  sinistrum  transverso  digito  con- 
tractus erat;  pes  in  neutram  partem  inclinabal  ;  trochan- 
ter sublimior,  et  extrorsutn  crassior  erat:  sulcus  qui  imtis 
terminum  designat,  pauJulum  versus  trochanterem  inflecte- 

batnr Ablaiis  muscnlis  femur,  de  quo  antea  dubita- 

bamus,  cum  cavitate  cotyloide  dearticulatum  esse  comperi- 
mus.  Capsam  articularem  a  parte  posteriori  liberam,  in 
solet ;  a  priore  vero  in  vicinia  foraminis  ovalis  cum  interno 
ligamen  o  accretam  deprehendimus ;  cujus  phaenomeni  ra- 

*   A'hvrsariii  Cliirnririea. 


20      GENERAL  OBSERVATIONS  ON  CONGENITAL 

tio  a  singulari  ipsiusmet  ligamenti  structura  pendebat.  Hoc 
enim  neque  in  funiculum  colligatum,  neque  in  prismatis 
modum  conformatum  erat,  sed  expansum  dijectumque  in 
form  am  membranae,  atque  sic  totam  acetabuli  superficiem 
occupabat ;  dumque  circulari  et  lato  exoriebatur  principio, 
mediam  relinquebat  cavitatem  fere  ad  formam  infundibuli, 
et  deinde  paulatim  fibras  contrahebat,  quo  capiti  propius 
accessisset.  Utrumque  cotylis  labrum  cartilagineum  nempe 
et  osseum  valde  depressum  erat ;  orijiciwn  ipsum  cotylis 
fere  ovale,  latius  nempe  a  superiori  parte,  et  ab  ima  magis 
coarctatum.  Ab  acetabuli  centro  usque  ad  marginem  seg- 
menti  inferioris  surgebat  tuber,  aut  colliculus  osseus,  lawi 
contectus  cartilagine,  atque  convexus,  qui  ubi  diligentius 
observabatur,  ab  ilii  ossis,  qui  in  acetabulum  concurrit,  pro- 
cessu  prseter  modum  crassescente  videbatur  productus, 
Frmur,  pene  dixerim,  acephalum  fuit ;  nam  complanatam 
habebat  faciem,  qua  sese  aptabat  tuberi  ex  cavitate  articu- 
lari  prominentir* 

Here  again,  as  in  the  following  case,  we  have  a  descrip 
tion  of  pathological  appearances  found  to  exist  at  the  ilio- 
femoral articulation,  which  have  but  little  affinity  with  an) 
other  of  the  affections  of  this  part,  than  those  occurring  as. 
the  result  of  the  congenital  form  of  displacement  of  the  liead 
of  the  femur.  The  same  author  thus  proceeds  with  another 
observation  of  a  case  which  afforded  an  opportunity  for  the 
autopsy  ; — "  Eadem,  ut  siguificavi,  die  inter  multa  alia,  ca- 

*  Adversaria  Chirurgica. 


DISLOCATIONS    OF    THE    HEAD    OF    THE     FEMUR.  -'1 

daver  hominis  robusti  qui  ex  morbo  inflammatorio  deces- 
serat  se  obtulit,  cujus  dexterum  crus  decurtatum  erat. 
Artu  diligenter  examinato,  collatoque  cum  sinistro  duobus 
transversa  digitis  deficere  animadocrti ;  natis  sulcus  pan  In 
ti/fior,  et  magis  incurvntus  erat ;  nee  praterea  alterius 
morbi  signum  ullum  extrinsecus  notabatur.     Dum  capsula 

articularis  incideretur,  qua?  justo  densior  apparuit ; 

caput  ovatum,  a  summo  latins,  dein  convergendo  in  obtu- 

sum  rostrum  abibat ; ligamentum  teres 

validissimum  fait  ex  duobus  fasciculis  compositum,  primum 
quidem  invicem  decussatis,  dein  expansis  in  trianguli  for- 
mam,  cujus  una  radix  anterior,  posterior  altera,  tertia  de- 
mum  inferior  ad  pedis  anserini  similitudinem  alte  in  sinum 
acetabuli  defigebantur.*     Cotyle  ossis  depurati  ad  conoi- 

deam   pariter   figuram   accedebat ; fundi  autem 

cotyloid  is  media  pars  superior  cartilaginem  suam  habebat; 
altera  cartilagineorbataperamplam  pro  triangulari  ligamento 
aivam  ostendebat.  Femoris  collum  erat  breve,  novem  li- 
nearum,  transverse  positum,  cujus  caput  magis  repandom 
pro  ratione  amplitudinis  acetabuli,  margines  suos  a  parte 
inferiori,  posteriorique  multum  ultra  collum  exporrectos 
habebat,  atque  ab  ima  parte  in  rostrum  aduncum  produce- 
batur,  interjecto  profundo  sinu  inter  femur,  et  rostri  curva- 
turam  ;  retrorsum  vero  idem  excrescens  margo  sic  dilata- 

*  It  is  probable  that  this  account  of  tho  ligamentum  teres  is  drawn  from  the  liga- 
mentous agglomeration  which  sometimes  occurs  between  the  capsular  ligament  and 
the  ligamentum  teres,  which  become  converted  into  a  strong  fibrous  cord,  as  will  be 
s.  en  in  a  case  described  hereafter  (vide  plates  viii.  and  ix.). 


22  GENERAL    OBSERVATIONS    ON    CONGENITAL 

batur,  ut  tribus  duntaxat  lineis  a  minori  trochantere  dis- 
taret.  Et  quamquam  anterius  ob  colli  brevitatem  margo 
capitis  naturalis  et  femori,  et  trochantere  proximior  esset, 
posterius  tamen  spatium  illud,  quod  est  inter  caput,  et 
utrumque  trochauterem,  pollicem  unum,  et  tres  lineas  la- 
tum reperiebatur ;  atque  id  ex  eo  contigit,  quod  caput 
oblique  positum  in  priorem  partem,  et  simul  in  inferiorem 
declinaret;  proptereaque  trochanter,  qui  extrinsecus  emi- 
nebat  plurimum,  totum  etiam  pollicem  ipso  capite  eminen- 

tior  erat Capitis  centrum  occupabat  area  scabra, 

....  ad  cujus  terminum  longe  infra  capitis  medium 
ligamenti  teretis  sinus  erat  conspiciendus."* 

The  details  of  these  cases,  taken  from  Palleta,  although 
not  as  complete  or  minute  as  those  resulting  from  more 
modern  investigations,  are  yet  sufficiently  distinct  in  their 
character  to  preclude  the  supposition  of  any  of  them  be- 
ing referable  to  a  traumatic  dislocation  or  fracture,  or  to 
any  morbid  or  accidental  lesion  likely  to  occur  at  the  hip- 
joint,  other  than  the  peculiar  articular  displacement  which 
takes  place  at  the  ilio-femoral  articulation  during  intra- 
uterine existence.  They  are  interesting,  as  being  the 
earliest  attempts  to  illustrate  anatomically  this  curious  point 
of  surgical  pathology,  and  in  giving  an  account  of  those 
cases  which  have  come  under  my  own  observation,  I  shall 
have  occasion  to  allude  to  them  again. 

Dupuvtren,  without  taking  any  notice  of  the   several 

*  Adversaria  Chirurgica. 


DISLOCATIONS  OF  THE  READ  OP  THE  FEMI  R.    23 

observations  of  the  learned  Palleta,  published  in  1826  his 
Essay,  entitled  "Memoire  sur  le  deplacement  originel ou 
congenital  de  la  tite  du  femur"*  Tliis  production,  clear 
in  its  descriptions,  and  practical  in  its  tendency,  attracted, 
when  first  issued,  considerable  attention  among  the  scien- 
tific men  of  the  French  capital. 

On  the  continent  of  Europe,  where  pathology  is  studied 
with  so  many  advantages  and  with  such  assiduity,  this 
point  of  surgical  inquiry  into  the  congenital  dislocations 
of  the  hip-joint  has  been  elucidated,  in  more  modern  times, 
by  contributions  from  Breschet,  Sedillot,  Pravas,  &c,  and 
particularly  from  Jules  Guerin,  who  has  entered  more  phi- 
losophically than  other  writers  into  the  etiology  and  treat- 
ment of  this  particular  class  of  dislocations. 

The  obscurity  of  the  nature  of  this  diseased  condition 
of  the  coxo-femoral  articulation,  and  the  circumstance  of 
its  being  a  lesion  which  occurs  before  birth,  has  deterred 
surgeons,  until  recently,  from  attempting  any  therapeutic 
means  to  bring  about,  and  render  permanent,  the  natural  re- 
lation of  the  displaced  articulation;  and  many  enlightened 
practitioners  have  supposed  permanent  reduction  to  be  be- 
yond the  reach  of  art.  Of  late  years,  cases  have,  how- 
ever, been  reported  of  successful  attempts  having  been 
made  to  reduce  fixedly  the  head  of  the  femur  to  its  natu- 
ral position  ;  and,  to  bring  about  this  result,  one  French 
surgeon,  referring  this   dislocation  to  the  theory  of  active 

•  Read  before  tho  Academy  of  Sciences  l-'Jii. 


24       GENERAL  OBSERVATIONS  ON  CONGENITAL 

muscular  retraction  {retraction  musculaire  active)  as  its 
cause,  lias  advised,  and,  in  accordance  with  notions  founded 
on  this  supposition,  put  into  operation,  the  sub-cutaneous 
section  of  the  muscles  supposed  to  be  implicated,  as  well 
as  of  the  new  fibrous  structure  that  may  have  been  adven- 
titiously thrown  out  as  a  consequence  of  the  abnormal  po- 
sition of  the  articulating  surfaces. 

The  varieties  of  the  congenital  dislocations  of  the  fe- 
mur, in  regard  to  the  position  which  the  head  of  the  bone 
may  occupy  relatively  to  the  circumference  of  the  aceta- 
bulum, have  been  enumerated  as  being  four  in  number ; 
the  luxation,  however,  upwards  and  outwards  upon  the 
dorsum  of  the  ilium  being  by  far  the  most  common.  The 
other  forms,  occurring  only  in  monstrosities,  are  not  met 
with  under  circumstances  where  surgical  relief  is  required, 
and  therefore  merit  but  a  cursory  allusion.  They  have 
been  described  as  occurring,  firstly,  directly  upwards;  se- 
condly, forwards  and  upwards ;  thirdly,  a  sub-luxation 
backwards  and  upwards.  * 

Lastly,  the  term  pseudo-luxation  has  beeu  applied  to 
certain  permanent  deviations  in  the  direction  of  the  femur, 
resulting  from  a  morbid  muscular  retraction  simulating  dis- 
location at  the  joint,  but  without  the  exit  of  the  head  of 
the  femur  from  the  cotyloid  cavity. 

The  causes  of  these  pathological  phenomena  are  not 
so  free  from  obscurity  as  to  be  beyond  controversy.  Nearly 
every  writer  who  has  given  attention  to  this  subject,  has 


DISLOCATIONS    OF    THE    FEMUR. 

assumed   a  hypothesis  to  account   for  the  origin  of  the 
displacement,  and  has   found  ingenious  arguments  to  sup- 
port his  conjectures.     Some  authors  construct  their  theon 
on  ideas  connected  with  the  evolution  of  ih<'  embryo,  and 
refer  the  incipiency  of  the  morbid  condition  of  the  joint 
to  an  arrit  fife  develappement,  to  an  aberration  of  the  nutri- 
tive forces  (fo7'ce  formatrice),  or  to  a  primitive  alteration 
of  the  genu.     Others,  unable  to  comprehend  that  the  head 
of  th«'   femur  can   be  transported  from  its  natural  recepta- 
cle without   the  aid  of  a  cause  analogous  in  some  way  to 
that    )f  traumatic   luxations,  attribute  the  displacement  of 
the  femur  to  improper  traction  exercised,  by  the  accoucheur, 
upon    the   extremities  of    the    infant,    during    its  passage 
through   the  pelvis   of  the  mother.     Again,  external  vio- 
lence acting  upon  the  foetus,  while  it  is  in  utero,  has  been 
assigned  as  a  cause.     Also,  the  contractions  of  the  uterus 
and  of  the  abdominal  muscles  upon  the  extremities  of  the 
Levers  presented  bj  the  long  bones  of  the  inferior  members 
of  the  child,  the   unnatural  position   occupied,  perchance, 
by  the   foetus   in    the  cavity  of  the  womb,  the  absence  of 
the  liquor  amnii,  permitting  the  walls  of  the  uterus  to  act 
directl)  upon  the  foetus  during  the  contractions  of  this  or- 
gan,  have  been  regarded  as  mechanical  antecedents,  which. 
acting  separately,  or  in  combination,  might  displace  the 
head    of  the    femur    from    its    natural  situation.      .More  re- 
cently, it  has  been  attempted  to  trace  an  analog)  between 
the  congenital    form,  and    that    species  of  luxation  which 

3 


26  GENERAL    OBSERVATIONS    ON 

occurs  at  different  periods  of  life,  as  the  result  of  relaxa- 
tion of  the  muscular  and  ligamentous  structures  surround- 
ing the  joint.     One  recent  author  has  gone  so  far  as  to 
take  up  again  the  theory  of  the  ancients  regarding  certain 
articular  displacements,  and    has  attributed  the  abnormal 
position  of  the  articular  apparatus  of  the  hip-joint,  which 
takes  place  in  the  foetus  before  birth,  to  the  relaxation  and 
elongation  resulting  from  an  effusion  into  the  cavity  ol  the 
articulation  whilst  the  child  is  still  in  utero.     On  the  other 
hand,  it  has  lately  been   maintained  that  the  articular  ap- 
paratus, in  the  cases  under  consideration,  is  always  prima- 
rily in  a  state  of  integrity,  and  that  the  derangement  which 
takes  place  in  utero  at  the  articulations,  destroying  the 
normal  relations  of  the  component  parts   of  the  joints, 
without  leaving  any  evidences  or  traces  of  inflammatory 
action,  is  dependent  upon  a  morbid  retraction  of  a  portion  of 
the  muscular  tissue,  resulting  from  a  defect  in,  or  absence 
of,    some    portion    of    the    nervous    centres.     My    own 
opinion  is,  that  the  displacements  of  the  hip-joint  in  ques- 
tion are  the   result  of  spasmodic  muscular  retraction,  not 
dependent,  however,  upon  mere  absence  of  the  central  ner- 
vous substance,  hut  upon  an  irritation  conveyed  to,  or  ori- 
ginally existing  in,  the  ganglionic  centre  of  the  medulla 
spinalis.      This  irritation  or  altered  action,   which  occa- 
sionally may  result  in  structural  lesion,  is  thence  transmit- 
ted by  the  reflex-motor  power  of  the  excito-motor  appa- 
ratus of  the  spinal  system  upon  the  muscles,  which  conse- 


DISLOCATIONS    OP    THE    FKMi  l;.  27 

quently  become  affected^  mid  In/  their  continued  retraction 
disarticulate  the  head  oj  the  femur.  This  last  theory  is 
based  iij)i)ii  physiology,  and,  if  assumed  as  a  law,  may  be 
made  available  to  explain  the  existence  not  only  of  the 
dislocations  of  the  hip-joint  occurring  before  birth,  but 
also  of  many  other  congenital  articular  displacements  found 
in  die  trunk,  and  extremities. 

Notwithstanding  tbese  conflicting  hypotheses  as  regards 
the  cause  of  this  peculiar  species  of  displacement  at  the 
ilio-femoral  articulation,  it  is  generally  admitted  tbat  here- 
ditary predisposition  has  a  certain  agency  in  die  occur- 
rence of  the  congenital  dislocation  of  die  hip-joint,  as  it 
has  been  acknowledged  to  have  in  the  various  kinds  of 
club-foot  or  talipes. 

Dupuytren  relates  a  curious  history,  which  was  commu- 
nicated to  him  of  a  family  living  at  Nantes,  in  France,  in 
which,  as  many  individuals  belonging  to  it  were  found 
affected  with  this  displacement  of  the  femur  occurring  be- 
fore birth,  this  peculiar  predisposition  may  be  supposed  to 
have  been  developed  in  an  extraordinary  degree;  and  as 
there  is  no  instance  recorded  more  illustrative  of  this 
point,  I  shall  transcribe  the  description  given  hj  him  in 
one  of  his  "Legons  Orales  de  Clinique  Chirurgicale"  de- 
livered at  the  Hotel  Dieu  of  Paris.  He  proceeds  as  fol- 
lows:— "  We  shall  now  relate  a  very  curious  one  (lac 
which  appears  to  indicate  that  this  vice  of  conformation 


28  GENERAL    OBSERVATIONS    ON 

can  be  transmitted  to  mauy  generations  of  individuals  of 
the  same  descent. 

"  There  exists,  in  the  town  of  Nantes,  a  family,  many 
members  of  which  have  been,  and  are,  affected  with  origi- 
nal luxation  {luxation  originelle)  of  the  femurs.  The 
oldest  member  of  this  family  is  a  woman  eighty  years  of 
age,  named  Marguerite  Gardas,  fruiterer,  and  here  follow 
the  particulars  of  her  case,  taken  from  her  own  lips,  and 
corroborated  by  other  persons  of  the  same  age. 

"  Two  of  her  aunts,  on  the  maternal  side,  who  died 
at  seventy  years  of  age,  had  been  affected  with  a  lame- 
ness from  their  earliest  attempts  at  walking.  These  females, 
moreover,  were  in  the  habit  of  stating  that  they  had 
always  been  lame.  Their  hips  were  elevated,  protuberant, 
and  abruptly  salient.  They  walked  with  their  elbows 
projecting  backward,  and  hobbled  like  ducks.  Mar- 
guerite's father  had  had  a  sister  lame  upon  the  right  side 
from  birth,  who  died  at  eighty  years  of  age.  Another 
sister,  who  was  well  formed,  gave  birth  to  a  female  child, 
which  presented  a  shortening  of  the  right  inferior 
extremity. 

••  .Marguerite  Gardas,  who  is  the  subject  of  this  observa- 
tion, is  a  large  and  robust  woman,  and  appears  to  have 
possessed  a  remarkable  degree  of  activity  in  her  youth. 
With  her  the  disease  was  not  prominently  marked  until 
she  was  thirty  years  of  age,  and  its  symptoms  are  those  of 


DISLOCATIONS    OF    THE    FEMUR.  29 

;i  spontaneous  luxation*  (luxation  spontanee)  of  the  Femur. 
Tin*  affected  member  is  one  fourth  less  in  diameter  than 
the  other,  which  is,  besides,  three  or  four  lines  longer. 
This  woman  has  had,  by  her  marriage  with  a  health} 
man,  who  had  come  from  distant  parts,  a  daughter  named 
Simone,  who  has  a  congenital  shortening  of  the  right 
inferior  member  of  about  three  inches.  This  girl  is  also 
married  to  a  man  of  healthy  conformation,  but  whose 
father  had  a  congenital  luxation  of  both  femurs;  she  has 
had  four  children,  two  of  whom  present  the  hereditary 
infirmity.  The  one  is  a  young  woman  aged  twenty-three 
years;  she  has  a  luxation  of  the  two  femurs,  the  heads  of 
which  are  situated  in  the  external  iliac  fossa;  the  other  is 
a  young  man  twenty-one  years  of  age,  who  has  a  con- 
genital luxation  of  the  left  thigh.  The  member  affected 
is  shorter  by  five  inches  than  the  other;  the  head  of  the 
lemur  has  ascended  upwards  and  backwards;  the  trochan- 
ter major  projects  forwards  and  outwards,  and  the  toes  are 
turned  inwards;  the  two  extremities  are  equally  well 
developed." 

After  the  recital  of  this  instance,  it  would  be  difficult  to 
doubt  that  hereditary  predisposition  exerts  some  influence 
over    the    recurrence  of   this   disease   in    children    wh 
parents  or  ancestors  had  previously  been  affected  l>\  it. 

Another  opinion  is  entertained,  and  generally  agreed 

•The   word  apontanee,   in    the   French    text,   is  here    used   as   .-yn.>nymon.-    wuli 
origineUe. 


30  GENERAL    OBSERVATIONS    ON 

upon  to  be  correct,  in  relation  to  the  more  frequent  occur- 
rence of  the  congenital  form  of  dislocation  at  the  hip  in 
the  female  than  in  the  male  sex;  and,  although  I  cannot 
coincide  entirely  with  Dupuytren  when  he  says  that 
"  presque  tons  les  individus  affect es  de  cette  luxation  sont  du 
sexe  feminin,"  I  am  satisfied  from  my  own  observation 
that  the  majority  of  persons  in  whom  this  disease  is  found 
to  exist  are  females,  and  that  the  proportion  of  males 
affected  should  not  be  put  down  at  more  than  one  third. 
The  cause  of  this  greater  proneness  may  possibly  proceed 
from  the  susceptibility  of  the  female  organization  to  be 
more  easily  impressed  by  the  existence  of  any  morbid 
irritation  of  the  nervous  centres,  which  might  be  incited 
during  the  period  of  evolution  of  the  embryo  or  foetus  ; 
and  not  improbably  in  connexion  with  this,  or  by  itself 
alone,  the  anatomical  configuration,  such  as  the  more  for- 
ward position  of  the  acetabulum  in  the  female  pelvis, 
might  facilitate  the  action  of  the  pelvi-trochanteric  mus- 
cles when  once  thrown  into  a  state  of  active  morbid 
retraction,  in  producing  the  displacement  of  the  head  of 
the  femur  from  its  natural  cavity. 

The  pathological  appearances  met  with  in  cases  of  con- 
genital dislocation  vary  with  the  period  of  life  at  which 
they  are  subjected  to  examination.  The  alterations  obser- 
vable in  the  articulations  and  the  ligamentous  structures 
concerned  in  the  malady  are  greatly  diversified.  "  In 
fact  the  primitive  characters  of  this  disease  become  more 


DISLOCATIONS    OF    THE    FEMUR.  3] 

extensively  modified  in  proportion  as  they  are  more  remote 
from  its  commencement.  There  arrives,  indeed,  a  period 
when  the  alterations  which  are  met  with  would  not.  even 
indicate  a  primitive  lesion,  were  it  not  that  in  some  cases 
these  very  lesions  had  been  previously  found  to  exist.  In 
relation  to  the  congenital  luxations,  we  are  not  permitted 
to  see  them  produced.  When  we  are  able  to  examine 
them  they  have  generally  existed  for  some  time  ;  conse- 
quently the  primitive  lesions  are  modified  by  so  much  as 
the  age  of  the  patient  is  advanced.  It  is,  then,  in  young 
subjects  that  the  essential  character  of  congenital  displace- 
ments must  be  sought ;  for  it  is  at  this  early  age  that  the 
changes  are  least." 

The  extensive  alterations  met  with  in  adult  life  are  not 
to  be  seen  in  the  congenital  dislocations  of  the  hip-joint  in 
the  new-born  infant.  In  the  latter,  the  signs  of  displace- 
ment are  less  marked  than  in  the  former.  The  soft  tissues 
surrounding  the  articulation  depart  but  little  from  the  nor- 
mal structure ;  the  capsular  ligament  has  as  yet  undergone 
but  trivial  change  in  its  form  or  dimensions,  and  is  found 
only  lengthened  and  put  upon  the  stretch  by  the  partial 
ascent  of  the  head  of  the  femur ;  and  the  articulating  sur- 
faces of  the  acetabulum  and  of  the  head  of  the  femur  are 
found  to  be  still  in  nearly  a  natural  condition.  But  in  the 
progress  of  advancing  age,  changes  occur  which  com- 
pletely modify  the  relations  of  the  whole  of  the  articular 
apparatus  of  the  joint.     The  head  of  the  femur  become 


32  DISLOCATIONS    OF    THE    FEMUR. 

softened,  atrophied,  or  completely  removed ;  the  acetabu- 
lum becomes  more  or  less  contracted  and  altered  in  shape, 
and  is  sometimes  filled  up  with  a  new  semi-osseous  mate- 
rial; and  the  fibrous  capsule  assumes  an  entirely  novel  ap- 
pearance, presenting  sometimes  a  cavity  retaining  the  head 
of  the  femur,  sometimes  a  perforation  which  allows  of  its 
transit,  sometimes  an  agglomerated  fibrous  cord  running 
between  the  remains  of  the  ancient  acetabulum  and  the 
atrophied  remains  of  what  was  originally  the  head  of  the 
femur.  Likewise,  the  head  of  the  femur,  escaping  from 
its  natural  capsule,  contracts  new  relations ;  a  new  fibrous 
capsule  is  formed  for  it,  and  either  a  depression  is  shaped 
out  for  the  reception  of  the  displaced  head,  or  an  acetabu- 
lum of  new  formation,  less  profound,  but  similar  to  the 
osseous  effusion,  which  frequently  takes  place  in  cases  of 
unreduced  traumatic  luxation  at  this  part,  springs  up  from 
the  surface  of  the  dorsum  of  the  ilium,  as  an  effort  of  na- 
ture to  give  support  to  the  unfixed  bone.  The  muscles, 
and  other  soft  tissues,  undergo  corresponding  perversion 
from  their  normal  condition  ;  and  the  bones  appertaining 
to  the  dislocated  limb  participate  in  the  general  derange- 
ment, by  showing  a  deterioration  in  their  development  and 
structure  as  regards  their  natural  length,  volume,  and  con- 
sistence. 


Z  tdi.  c/  Sarony  tMeuc 


EXPLANATION  OF  PLATE   No.   III. 

Posterior  view  of  the  Foetal  Pelvis — about  the  end  of  the  ninth  month. 

The  drawing  represents  a  dissection  of  the  parts  concerned  in  Congenital  Dislo- 
cation of  the  Femur,  and  is  intended  to  explain  the  manner  in  which  the  head  "i 
the  lemur  may  escape  from  the  cotyloid  cavity  during  foetal  life ;  and  also  the 
mechanism  by  which  the  consecutive  malformations  are  brought  about,  chiefly  by 
means  of  muscular  traction. 

X   The  right  Femur,  slightly  flexed. 

a  The  Dorsum  of  the  Ilium. 

6  Head  of  the  Femur. 

c  Trochanter  Major. 

d  Ligamentous  Margin  of  the  Acetabulum.     The  dotted  line  shows  the  portion  of 

the  acetabulum  which  is  cartilaginous  in  this  direction,  at  this  period — the  ilio- 

iscbiatic  depression  is  thus  formed. 
e  Ligamentum  Teres. 
/  Gluteus  Medius. 
g  Gluteus  .Minimus. 
h  Pyramidalis. 
»  Superior  Gemellus. 
k  Obturator  Interims. 
m  Inferior  Gemellus. 
a  ( tbturator  Bxternus. 
o  Quadratic  Femoris. 


35 


CHAPTER  II. 


ANATOMICAL    OBSERVATIONS. 


In  the  adult,  traumatic  dislocations  of  the  femur  from 
the  acetabulum  are  not  of  frequent  occurrence.  I  am  in- 
clined to  believe,  from  what  I  have  seen,  that  the  conge- 
nital form  of  luxation  of  the  femur,  more  especially  that 
variety  where  the  femur  ascends  upon  the  dorsum  of  the 
ilium,  is  of  as  frequent  occurrence,  if  not  more  so,  as  the 
corresponding  dislocation  caused  by  external  violence  dur-* 
ing  extra-uterine  life. 

During  adult  life,  various  causes  are  opposed  to  the  dis- 
placement of  the  head  of  the  femur  from  its  proper  recep- 
tacle. The  depth  of  the  acetabulum,  the  strength  of  the 
capsular  ligament,  aided  by  the  auxiliary  resistance  of  the 
ligamentum  teres,  the  resisting  influence  of  the  pelvi-fe- 
moral  muscles  which  surround  the  ilio-femoral  articulation, 
the  limited  motion  of  the  joint  in  certain  directions,  are 
obstacles  which  oppose  the  dislocation  of  the  femur  from 
its  natural  socket. 

On  the  other  hand,  during  foetal  life,  the  anatomical 
disposition   of  the  parts,   and    the   flexed    position    main- 


36  ANATOMICAL  OBSERVATIONS. 

taiiied,  generally,  by  the  thighs  upon  the  abdominal  wall 
during  this  epoch,  predispose  the  head  of  the  femur  to 
pass  from  its  shallow  acetabulum,  and  mount  upwards 
and  backwards,  in  the  direction  of  the  dorsum  of  the 
ilium. 

It  is  probable  that  intra-uterine  dislocations  of  the  hip- 
joint  may  occur  in  the  fcetus  from  spasmodic  muscular  re- 
traction as  early  as  the  third  or  fourth  month  of  gesta- 
tion. 

If  the  doctrine  be  correct,  as  I  suppose  it  to  be,  that  a 
morbid  condition  of  the  medulla  spinalis — as  one  of  the 
important  parts  of  the  spinal  excito-motor  circuit — must 
be  present,  in  the  production  of  intra-uterine  dislocations, 
the  previous  junction  with  the  medulla  spinalis  of  the 
nervous  trunks,  which  are  ultimately  ramified  in  the 
muscles  implicated,  must  also  be  essential.  Now,  accord- 
ing to  M.  Serres,  the  nerves  have  a  separate  evolution 
from  the  cerebro-spinal  axis,  and  pass  eentripetally  from 
the  organs  to  the  encephalon,  and  to  the  medulla  spinalis. 
This  junction  takes  place  between  the  optic  nerves  and 
the  tubercula  quadrigemina,  as  remarked  by  this  writer,  at 
about  the  end  of  the  second  month  ;  and  during  the  fourth 
month  they  become  joined  with  the  thalami  and  the  cor- 
pora geniculata. 

The  Rachidean  nerves,  following  the  same  law,  join 
the  medulla  spinalis  in  a  similar  manner,  and  probably 
about  the  same  time.      The  spinal  excito-motor  system 


ANATOMICAL    0BSER1  \tio\s. 

may  reasonably  be  supposed    to  COtne  into  pla\   then,    and 
not  previous  to  the  nervous  junction.* 

It  would  be  superfluous  to  trace  the  modifications  ob- 
servable at  the  hip-join!  during  the  different  phases  of 
embryotic and  foetal  life;  I  shall  only  therefore  take  a  cur- 
sory glance  at  the  anatomical  relations  of  the  ilio-feuioral 
articulation,  as  it  is  seen  about  the  middle  period  of  intra- 
uterine existence. 

In  the  adult,  two  bones  enter  into  the  formation  of  the 
osseous  part  of  the  ilio-femoral  articulation — the  os  inno- 
minatum  and  the  os  femoris.  In  the  foetus,  however,  a 
different  arrangement  results  from  the  fact,  that  ossifica- 
tion is  not  yet  completed  cither  at  the  acetabulum  or 
at  the  head  of  the  femur.  The  articular  part,  corres- 
ponding to  the  osseous  acetabulum  in  the  adult,  is  here 
partlv  cartilaginous.  The  three  portions,  now  called 
ilium,  ischium,  and  pubes,  and  which  ultimately  join  to 
form  one  bone,  the  os  innominatum,  are  seen  progressing 
towards  development,  by  the  deposition  of  osseous  material 
in  the  cartilaginous  matrix,  or  framework,  by  which,  ;it 
this    early    period,   the    acetabulum   is   chiefly    made    up. 


*  Several  anatomists  have  recorded  examples  which  go  to  prove  the  separate 
lotion  of  the  nerves  and  >■!  the  nervous  centres,  —  Lallemand  ,-/-•  Montpellier). 
Thiee  inaugurate. — Lonsdale. — Serrea,  Anatomie  <lr  Syst.  rwrv. — 1  bave  myself 
Been  an  amyllencephalous  embryo  of  aboul  the  fourth  month,  in  which  the  spinal 
nerves  seemed  to  terminate  in  tin'  vertebral  canal,  opposite  the  intervertebral  foramina, 
like  ;l  range  <■!  minute  dots. 


38  ANATOMICAL    OBSERVATIONS. 

These  three  osseous  portions,  in  their  centripetal  progress 
towards  final  development,  leave  between  them  three 
spaces,  occupied  in  the  recent  subject  by  cartilage ;  by 
means  of  which,  and  with  the  assistance  of  the  ligamen- 
tous border,  formed  by  the  cotyloid  ligament,  the  circular 
arrangement  of  the  cotyloid  cavity  is  completed  in  the 
foetus.  This  cotyloid  cavity,  at  the  fifth  month,  is 
found  to  measure  about  nine  lines  in  circumference, 
and  about  two  lines  in  depth.  If  the  parts  are  now  ex- 
posed to  the  air  for  a  short  time,  the  cartilaginous  compo- 
nents of  the  acetabulum  become  dried  and  shrunken,  and 
the  extent  to  which  the  osseous  portions  contribute  to 
form  this  cavity  is  exhibited  ;  the  three  depressions 
already  alluded  to,  and  which  were  scarcely  appreciable 
while  the  cartilage  of  the  acetabulum  was  in  its  natural 
state,  being  now  strongly  marked  around  its  perimeter. 
These  marginal  depressions  of  the  acetabulum  can  be 
seen  in  the  skeleton  of  the  adult  pelvis,  but  they  are 
much  more  distinct  in  that  of  the  foetus.  One  of  these 
depressions  is  situated  between  the  os  ischium  and  the  os 
pubis,  and  conducts,  as  it  were,  from  the  acetabulum 
to  the  foramen  ovale  ;  the  other  is  between  the  os  ilium 
and  the  os  pubis,  and  is  on  a  level  with  the  horizontal 
branch  of  this  bone  ;  while  the  third  occupies  the  poste- 
rior half  of  the  margin  of  the  acetabulum,  corresponds  to 
the  space  between  the  ilium  and  the  ischium,  and  leads 
towards  the  ischiatic  notch,  or  upwards  to  the  dorsum  of 


ANATOMICAL     OBSEIM   \Tlu\s.  tt) 

the  ilium.  This  last,  <>i'  ilio-ischiatic  depression,  which  in 
the  skeleton  of  the  foetus  is  seen  to  be  extensive,  and 
which  originally  was  filled  nj)  with  yielding  cartilaginous 
material,  may  permit,  during  foetal  life,  the  head  of  the 
femur  to  slip  readily  over  the  margin  of  the  acetabulum, 
which,  at  this  period,  and  in  this  direction,  is  so  shallow 
— as  observed  in  the  dried  state  of  the  parts — that  the 
margin,  at  its  most  depressed  point,  is  almost  on  a  level 
with  the  bottom  of  the  cotyloid  cavity.  By  this  anato- 
mical configuration,  and  the  pressure  of  the  head  of  the 
femur  towards  the  lower  and  posterior  part  of  the  acetabu- 
lum during  the  flexed  state  of  the  thighs,  the  exarticulation 
of  the  head  of  the  femur,  upwards  and  backwards,  to- 
w  aids  the  dorsum  of  the  ilium,  could,  evidently,  be  easily 
accomplished  by  spasmodic  muscular  retraction  prolonged 
and  acting  in  the  direction  of  the  force  which  would  be 
exerted  by  the  two  smaller  glutei,  and  by  some  of  the 
other  pelvi-femoral  muscles,  if  thus  morbidly  affected. 
Vide  Plate  hi. 

Above  the  acetabulum,  the  dorsum  of  the  ilium  is  seen 
presenting  upon  its  surface  a  slight  elevation  or  ridge, 
which  extends  from  the  anterior  third  of  the  crest  to  the 
upper  pari  of  the  acetabulum.  This  ridge,  only  slightly 
marked,  divides  the  dorsum  into  two  unequal  parts.  The 
more  posterior  presents  a  concave  surface,  which  becomes 
continuous  with  the  margin  of  the  acetabulum,  by  an  in- 
clined   plane,  upon   which   the  head   of  the   lemur,  when 


40  ANATOMICAL  OBSERVATIONS. 

dislocated,  will  glide  upwards  towards  the  external  iliac 
fossa  upon  the  dorsum.  Below  the  cotyloid  cavity,  and 
between  its  inferior  margin  and  the  tuberosity  of  the 
ischium,  is  the  groove  in  which  passes  the  tendon  of  the 
obturator  extern  us ;  while,  posteriorly,  are  seen  the 
spine  of  the  ischium,  still  cartilaginous,  the  groove  for  the 
passage  of  the  obturator  internus,  and  the  several  points 
which  give  origin  to  the  small  pelvi-trochanteric  muscles. 
J n  front  and  below,  is  the  obturator  foramen  filled  by  the 
membrane  of  the  same  name,  which  supports  on  its  two 
surfaces  the  origin  of  the  obturator  muscles.  Extending 
forward  from  the  anterior  portion  of  the  acetabulum,  is 
the  horizontal  branch  of  the  pubes,  terminating  in  its 
body.  The  horizontal  ramus  gives  attachment  to  the  pec- 
tineus,  while  the  anterior  surface  of  the  body  of  the 
pubes  and  its  descending  ramus,  and  the  ascending  branch 
of  the  ischium, — the  two  last  named  portions  being  still 
cartilaginous, — give  points  of  origin  to  the  other  adduc- 
tors of  the  thigh.  These  anatomical  details  have  a  bear- 
ing upon  the  mechanism  by  which  malformations,  conse- 
quent upon  (he  congenital  dislocations  at  the  hip-joint,  are 
produced.      Vide  Plate  hi. 

The  Acetabulum. — The  acetabulum,  composed  as  it 
is  of  the  three  osseous  facettes  which  the  ilium,  ischium, 
and  pubes  present  upon  the  inner  aspect  of  its  cavity,  and 
the  unossified,  cartilaginous   matrix  which  exists   between 


\  \  \  rOHIG  \l.     OB8ER1  \tio\s  I  1 

these  osseous  parts  is.  in  its  receni  state,  about  the  fifth 
month  of  gestation,  a  shallow  cavit}  of  about  two  lines 
in  depth,  and  i » i n « *  or  ten  lim's  in  circumference,  it  is  lined 
with  synovial  membrane  for  aboul  lour  fifths  of  its  extent 

superiorly,  and  presents  a  smooth  surface — the  portion 
uncovered  by  membrane  being  between  the  notch  and  the 
centre.  One  part  of  the  inferior  fifth  is  appropriated  for 
the  attachment  of  die  round  ligament;  the  other,  In  a 
fatt)  cellular  mass,  which  tends,  in  its  position,  to  dimi- 
nish the  depth  of  the  cavity.  The  cotyloid  ligament  sur- 
mounts the  margin  of  the  semi-osseous  and  semi-cartila- 
ginous acetabulum,  and  with  the  exception  ot  this  notch, 
through  which  the  articular  vess  Is  and  nerves  pass,  masks 
almost  entirely  the  marginal  depressions,  already  alluded  to 
as  existing  so  plainly  upon   the  skeleton. 

The  Head  of  the  Femur. — The  head  of  the  femur, 
which,  with  the  acetabulum,  composes  the  ilio-femoral  ar- 
ticulation, is  entirely  cartilaginous  during  foetal  life.  It 
is  nearly  globular,  forming,  as  it  dot's,  a  considerable  seg- 
ment of  a  sphere,  which,  in  the  recent  state,  is  about  three 
lines  in  diameter.  The  articular  cartilaginous  surface  is 
covered  b\  synovial  membrane,  and  presents,  at  its  inner 
and  inferior  part,  a  depression  for  the  insertion  of  the  li- 
gamentum  teres.  It  is  supported  l>\  the  neck,  the  pedicle 
of  which  is  but  little  developed.  The  trochanter  major 
is  also  cartilaginous;    it    gives   attachment    to    the    two 


42  ANATOMICAL  OBSERVATIONS: 

glutei  muscles,  which  take  their  origin  from  the  dorsum 
of  the  ilium,  aud  is  apparently  continuous  with  the  shaft 
of  the  femur;  its  summit  being  placed  on  a  plane  some- 
what below  the  highest  point  of  the  head  of  the  femur. 

Capsular  Ligament  and  Ligamentum  Teres  — The 
articulating  surfaces  of  the  semi-cartilaginous  hip-joint 
are  maintained  in  their  natural  relations  by  means  of  se- 
veral ligaments.  The  capsular  ligament,  which  in  the 
adult  is  strong,  is  delicate  in  the  articulation  of  the  foetus. 
It  is  attached  on  one  side  to  the  margin  of  the  acetabu- 
lum and  the  contiguous  surface  around  its  circumference  ; 
on  the  other,  to  the  neck  of  the  femur.  The  accessory- 
fibrous  band,  which  has  received  the  name  of  ligamentum 
sujjerius,  and  which,  in  the  adult,  strengthens  the  capsule 
anteriorly,  is  scarcely  perceptible  in  the  foetus.  The  cap- 
sule is  lined  upon  its  inner  surface  by  a  layer  of  synovial 
membrane,  which  passes  also  over  the  ligamentum  teres 
and  the  other  parts  of  the  articulation.  This  capsule, 
when  deprived  of  the  tendinous  expansions  and  muscu- 
lar tissue,  by  which  it  is  surrounded,  permits  the  head  of 
the  femur  to  be  separated  considerably  from  the  cotyloid 
cavitv. 

The  other  ligament,  called  the  round  ligament,  slight 
and  fragile  in  the  foetus,  extends  from  the  apex  of  the 
head  of  the  femur,  and  becomes  inserted  at  the  marginal 
notch   as  well  as   at   the  depression   found  at  the  ante- 


LNATOMICAL    OBSERVATIONS.  43 

rior    ;iikI    inferior   part    of   the    bottom   of   the    aceta- 
bulum. 

Tin1  intra-articular  vessels,  which  chiefly  subserve 
the  nutrition  of  the  head  of  tin*  bone,  pass  through 
this  marginal  notch,  which  becomes  converted  by  the 
transverse  ligament  into  a  distinct  foramen  ;  and  finally 
there  is  the  cotyloid  ligament,  tipping  the  margin  of 
the  cavity  with  a  delicate  ligamentous  border.  Vide 
Plate  hi. 

In  adult  life  many  muscles  are  grouped  around  the  iKo- 
femoral  articulation,  and  protect  the  joint  from  external 
injury  ;  but,  in  foetal  life,  if  struck  with  the  abnormal  state 
of  spasmodic  retraction  to  which  the  muscular  system  is 
liable,  they  become,  most  probably,  the  active  cause  of 
the  displacement  of  the  head  of  the  femur  from  its  natu- 
ral cavity.  Some  of  these  pelvi-femoral  muscles,  owing 
to  the  direction  of  their  fibres,  do  not  participate  in  pro- 
ducing this  dislocation.  After  birth,  however,  ami  at  a 
more  advanced  stage  of  the  case,  and  in  combination 
with  other  causes,  such  as  the  superincumbent  weight  of 
the  trunk,  and  the  ordinary  physiological  contraction 
which  the\  then  more  vigorously  exert,  they  tend  to  pro- 
duce by  their  abnormal  traction  those  consecutive  malfor- 
mations of  the  pelvis,  and  of  the  contiguous  osseous  tis- 
sue,  thai  constitute  one  of  the  chief  complications  accom- 
panying the  congenital  dislocation  of  the  femur  upon  ih<v 
ilium.      Vide  Plate  hi. 


44  ANATOMICAL    OBSERVATIONS. 

The  individual  action  of  the  muscles  concerned  in 
these  results  will  be  more  fully  stated,  when  the  subject  of 
the  pathology  comes  to  be  considered. 

A  consideration  of  the  anatomical  disposition  thus  pre- 
sented, of  the  component  parts  of  the  foetal  ilio-feinoral 
articulation,  and  of  the  influence  which  the  strong  mus- 
cles, inserted  into  the  upper  part  of  the  femur,  may  be 
supposed  to  exert  when  once  thrown  into  a  state  of  mor- 
bid retraction,  will  aid  materially  in  removing  the  difficul- 
ties in  accounting  for  the  displacement  of  the  femur  dur- 
ing intra- uterine  life. 

The  os  feinoris  of  the  foetus  is  generally  flexed  upon 
the  anterior  abdominal  wall,  and  consequently  the  head 
of  the  bone  is  pressed  against  the  posterior  and  inferior 
portion  of  the  shallow  acetabulum,  and  of  the  correspond- 
ing part  of  the  capsular  ligament.  By  this  disposition  of  the 
parts,  the  head  of  the  femur  is  supported  in  its  place,  as  it 
were,  in  a  sling,  composed  on  one  side  of  the  pelvi -tro- 
chanteric muscles  and  of  the  two  lesser  glutei.  While 
the  femur  is  in  this  position,  it  may  easily  be  supposed 
that  an  abnormal  and  continued  spasmodic  retraction  of 
these  muscles,  especially  of  the  glutei,  will  induce  the 
head  of  the  femur  to  slip  from  its  cavity  over  the  poste- 
rior part  of  the  margin  of  the  acetabulum,  upon  which  is 
observed  the  depression,  resulting  from  the  unossified 
space,  still  existing  betweeu  the  rudimentary  ilium  and 
ischium.     Having  once  passed  the  border  of  the  cotyloid 


ANATOMICAL    OBSERVATIONS.  I  •'. 

cavity,  i he  extension  of  the  limb,  after  birth,  will  throw 
the  head  of  the  femur  still  more  upon  the  ilium,  and  the 
retracted  muscles,  continuing  to  act,  in  combination  with 

other  causes  which  subsequently  come  into  play,  will  in 
the  progress  of  time  induce  the  head  of  the  femur  to 
glide  still  further  in  the  direction  of  the  fossa,  observed 
upon  the  dorsum  of  the  ilium,  and  thus  the  displacement 
is  effected  to  its  ultimate  limit. 


46 


CHAPTER  III. 

ETIOLOGY     OF    CONGENITAL      DISLOCATIONS      OF    THE     HEAD 
OF    THE    FEMUR. 

Like  the  ordinary  traumatic  dislocations  of  the  hip- 
joint,  the  dislocation  we  now  treat  of,  implies  a  removal 
of  the  articulating  portion  of  the  head  of  the  femur  from 
its  natural  receptacle,  the  acetabulum.  Occurring  during 
intra-uterine  life,  it  differs  materially  from  the  form  of  dis- 
location caused  by  external  violence,  in  its  origin,  progress, 
and  symptoms  ;  and  therefore  writers,  who  have  paid  at- 
tention to  this  point  of  surgery,  have  designated  it  by  a 
distinctive  name.  Some  have  applied  the  term  spontane- 
ous;  others  the  term  original;  and  others  again  the 
term,  congenital,  to  this  form  of  dislocation.  The  term 
spontaneous,  however,  has  also  been  used,  in  speaking  of 
the  displacement  which  occurs  at  the  hip-joint  as  a  result 
of  morbus  coxarius,  and  it  is  therefore  objectionable. 
The  word  congenital,  as  indicating  the  existence  of  the 
disease  when  the  child  comes  into  the  world,  seems  most 
applicable,  and  I  shall  therefore  adopt  it. 

The  congenital  dislocations  of  the  head   of  the  femur 
occurring  at  the  ilio-feinoral   articulation,  are  either  com- 


BTIOLOG1  .  I  J 

plete  ox  incomplete;  and  1 1 1 « •  \  ma}  exisi  upon  one  side 
<>nl\,  or,  as  inosl  frequently  happens,  the  displacement 
m;i\  <-\ i->i  simultaneously  on  both  .sides,  forming  ;i  double 
luxation. 

The  head  of  the   femur  ma}  be  complete!}  dislocated 
before  birth  in  three  different  directions: — 

Firstly,  upwards  and  outwards;  this  form  of  disloca- 
tion corresponds  to  that  variety  which  is  described  l>\  au- 
thors as  being  situated  upon  the  dorsum  of  the  ilium.  It 
is  the  variety  which  is  most  common,  and  to  it  prac- 
tical authors  have  chiefly  directed  their  attention.  The 
head  of  the  femur  is  here  situated,  in  the  new-born  child, 
above  the  margin  of  the  acetabulum;  and.  in  the  progress 
of  time,  mounts  upon  the  dorsum  of  the  ilium,  and  i 
in  the  externa/  iliac  fossa*  Of  this  variety  1  have  seen 
many  examples,  and  the  accompanying  plates,  taken  from 
an  adult  during  life,f  and  also  from  some  dissections  1 
have  made,  will  illustrate  the  appearance  and  nature  of 
the  luxation  in  this  direction.  This  form  is  general!}  a 
double  luxation,  but  it  is  also  met  with  upon  one  side 
only. 

Secondly,  the  luxation  direct!}  upwards.      This  kind  ot 
dislocation  has  been  seen  only  in  those  foetal  monstrosi 
which    have     been    called    agenosome,   in    which,    with 
other  anomalies,  the  abdominal  walls  are  not  complete!} 
developed      The  head  ol  the  femur  is  here  placed  iuime- 

•  Vide  F         vii.  t  Vide  Plates  L,  ii.,  an  i   •■ 


48  ETIOLOGY. 

diately  external  to  the  anterior  and  inferior  spinous  pro- 
cess of  the  ilium. 

Thirdly  the  luxation  forwards  and  upwards.  Like 
the  preceding,  this  displacement  has  been  only  met  with 
in  the  foetal  monstrosity.  The  head  of  the  bone  rests 
upon  the  eminentia  ilio-pectinea,  and  forms  a  well  marked 
tumor  in  the  groin. 

M.  Guerin  mentions,  in  addition  to  the  forms  already 
noticed,  a  sub-luxation  upwards  and  backwards,  which  in 
reality  appears  to  be  but  a  modification  or  incomplete  de- 
velopment of  the  dislocation  upwards  and  outwards.*  He 
describes  it  as  being  characterized  by  the  partial  escape  of 
the  head  of  the  femur,  which  does  not  pass  beyond  the 
margin  of  the  acetabulum.  This  variety  is  met  with  in 
new-born  children,  and  sometimes  in  cases  where  luxation 
from  muscular  retraction  has  occurred  spontaneously  soon 
after  birth. 

Tbe  same  author  has  also  indicated  two  varieties  of 
what  he  terms  pseudo-luxations  of  the  hip  ;  one,  simulat- 
ing a  luxation  back  wards  and  outwards  ;  the  other,  resem- 
bling a  luxation  downwards  and  forwards.  "  There  exists," 
he  says,  "  an  order  of  congenital  dislocations  of  the  hip,  to 
which  I  have  given  the  name  of  pseudo-luxations,  because 
they  present  the  fallacious  appearance  of  luxations,  al- 
though  the  head   of  the  femur  has  not  escaped  from  the 

*  Strictly  speaking,  the  head  of  the  femur,'  in  the  dislocation  upon  the  dorsum  of 
the  1  :  m,  passes  upwards  and  backwards.  I  have  retained,  however,  the  designation 
adopted  by  Dupuytreu,  "  en  haut  et  en  dehors." 


ETIOLOGY.  49 

cotyloid  cavitj  ;  the  varieties  of  these  pseudo-luxations 
are  themselves  the  result  of  the  muscular  retraction, 
duTerentlj  distributed  among  the  pelvi-femoral  muscles." 

This  pathologic  condition  of  the  pelvi-femoral  muscles 
had  alreadj  beeB  noticed  !>\  Delpech,*  and  the  novelty 
presented  by  M.  Guerin  consists  in  the  adoption  of  a  de- 
signating term,  which  serves  a  useful  purpose  in  individu- 
alizing a  class  of  affections. 

From  this  enumeration  of  the  varieties  of  the  congeni- 
tal dislocations  occurring  at  the  hip-joint,  it  will  be  seen 
that  several  of  them  are  only  to  he  met  with  in  the  im- 
perfectly developed  foetus,  and  consequently  cannot  come 
within  the  range  of  surgical  practice  :  others,  however, 
are  met  with  in  the  living  individual,  and  become  the  ob- 
ject of  remedial  attention  The  former  are  interesting  in 
a  scientific  point  of  view  only  ;  the  latter  belong  to  the 
practical  details  of  the  profession. 

To  no  other  class  of  maladies  is  the  phrase,  "felix  qui 
yotuit  rerum  cognoscere  causas"  more  applicable  than  to 
the  congenital  dislocations  observed  at  the  ilio-femoral  ar- 
ticulation. 

The  researches  into  the  origin  and  nature  of  the  class 
of  displacements  which  occur  at  the  articulations  of  the 
lotus,  while  still  in  the  womb  of  the  mother,  haw  perhaps 
suggested  more  ingenious  hypotheses  than  any  other  of 
the  obscure  parts  of  surgical  pathology.  Laying  aside 
the  predisposition  engendered  by  hereditary  transmission, 

'   l  >•■  l'(  Irthomorphie  par  rapport  a  t\  sp&ce  bumaine. 


50  ETIOLOGY. 

and  by  sex,  as  being  generally  concurred  in,  the  other 
causes  mentioned  by  writers,  as  tending  to  bring  about 
the  dislocation  in  question,  may  be  referred  to  different 
heads.  First,  external  violence,  acting  upon  the  foetus 
while  in  utero  (J.  L.  Petit) ;  second,  a  primitive  altera- 
tion in  the  germ,  or  an  aberration  of  the  formative  power 
(force  formatrice)  (Dupuytren)  ;  third,  an  arrest  in  the 
development  of  the  osseous  portions  forming  the  cotyloid 
cavity  (Breschet )  ;  fourth,  certain  articular  maladies,  oc- 
curring in  the  foetus  during  intra-uterine  life  (revived  by 
M.  P  arise  and  others)  ;  fifth,  a  primitive  alteration  in  the 
nervous  centres  (Chaussier),  revived  by  Delpech  and  Gue- 
rin  ;  and  lastly,  to  be  more  definite,  I  would  add  to  the 
causes  mentioned  above,  a  pathological  spasmodic  reti ac- 
tion of  the  muscular  tissue,  resulting  from  a  perverted  or 
disturbed  condition  of  the  excito-motor  apparatus  of  the 
medulla  spinalis  ;  especially  of  that  portion  which  is  in  direct 
relation  with  the  nervous  branches  distributed  among  the 
pelvi-femoral  muscles. 

J.  External  Violence. — Hippocrates,*  as  before 
stated,  says,  that  children  yet  contained  in  the  organ  of 
gestation,  may  have  the  arms  or  the  inferior  limbs  dislo- 
cated by  falls,  blows,  or  by  pressure  exerted  upon  the  ab- 
dominal walls  of  the  mother. 

The  powerful  contractions  of  the  uterus  acting  upon 
the  extremities   of  the   levers    presented    by  the  femurs, 

*  Liber  de  Articulis. 


ETIOLOGY.  5] 

while  the  thighs  are  flexed  upon  the  abdomen,  and  the 
effecl  ofviolenl  tractions  exercised  by  the  accoucheur  upon 
the  inferior  extremities  daring  a  difficult  parturition,  as 
suggested  by  Pare,  have  also  been  regarded  as  sufficient 
to  account  for  the  displacement* 

It  is  certain  that  dislocations  at  the  hip-joint,  from  trau- 
matic causes,  are  exceedingly  rare  in  early  life,  and  anj 
force  originating  externally — and  of  a  mechanical  kind — 
of  sufficient  energy  to  act  upon  the  foetus  in  utero,  might 
he  supposed  to  produce  fracture  rather  than  dislocation. 
The  tendency  to  hereditary  transmission,  and  the  frequent 
occurrence  of  congenital  dislocation  in  the  double  form. 
and  closely  similar  on  both  sides,  would  go  to  disprove 
the  agency  of  any  purely  mechanical  cause  in  the  pro- 
duction of  intra-uterine  dislocation  of  the  hip-joint. 

The  position  of  the  inferior  memhers  of  the  foetus, 
while  it  is  contained  in  the  uterus,  has  been  brought  for- 
ward to  give  probability  to  the  effect  said  to  be  produced 
h\  causes  of  external  origin.  Before  birth,  as  a  general 
rule,  the  thighs  of  the  child  are  flexed  upon  the  abdomen ; 
and  the  heads  of  the  femurs  consequently  must  make  a 
continual  pressure  upon  the  posterior  and  inferior  portion 
of  the  capsule  of  the  joint.  This  circumstance  is  no 
doubl  favorable  to   the  displacement  of  the  head  of  the 

*  "  Ce  que  aduient  auasi  souuentesfoi    aua  enfantemena  difficile  quand  lea 
femmes   tirana   lea  brae  dea  enfans,  dealoquenl  lea  iointurea  de  I'eepaule  ou  de  i;i 
■  ■." — Pari,    Chapitre    L4me,     Livre     L4ffw.      Edition    by    Malgaigne—{Old 
French). 


52  ETIOLOGY. 

femur  from  its  natural  receptacle,  but  it  is  more  in  co-re- 
lation with  the  agency  of  morbid  muscular  retraction,  to 
which  further  allusion  will  be  presently  made.  Taking 
into  consideration  what  has  just  been  stated,  and  the  proba- 
ble action  of  more  potent  causes,  originating  primarily  in  the 
foetus  itself,  it  does  not  appear  that  external  injury,  or  mere 
mechanical  agency,  could  have  much  influence  in  the 
production  of  intra-uterine  dislocations  of  the  head  of  the 
femur. 

II.  An  Original  Defect  in  the  Organization  of 
the  Germ,  or  Aberration  of  the  Formative 
Power. — This  hypothesis  of  Dupuytren  is  sufficiently 
vague  and  inexplicit.  It  refers  the  origin  of  the  displace- 
ment to  the  first  organization  of  the  embryo,  or,  in  other 
words,  to  an  original  vice  of  conformation,  which  depends 
upon  a  defect  in  the  constitution  of  the  germ.  Adopting 
this  theory,  he  says :  "  We  may  very  well  conceive  the 
simultaneous  displacement  of  both  femurs,  as  is  observed 
in  most  individuals  affected,  the  perfect  health  which 
they  enjoy  at  birth,  and  the  complete  absence  of  morbid 
action,  or  of  symptoms  of  a  previous  or  present  malady, 
either  around  the  head  of  the  femur  or  in  the  cotyloid 
cavity." 

This  hypothesis  of  Dupuytren  is  unsatisfactory,  and  has 
no  support  from  physiological  facts,  or  the  acknowledged 
doctrines  regarding  Embryogeny. 


ETIOLOGY. 

III.  Arrest  <>f  Development  at  the  Cotyloid 
Cavity. — (  Am  f  <l<  developpement  de  la  Ccwite  (  btylo'ide.) 
— .M.  Breschet  refers  the  congenital  luxations  of  the  head 
of  the  lemur  to  the  laws,  which,  from  Ins  researches,  he 
supposes,  govern  the  evolution  of  tin-  osseous  system  of 
the  foetus  or  of  the  embryo,  and  he  considers  these  dis- 
placements as  the  result  of  an  arrest  of  the  development 
of  the  cotyloid  cavity.  He  asserts  that  the  osseous  cen- 
tres, from  which  development  is  last  completed,  are  those 
from  which  the  cavities  and  processes  result,  as  is  exem- 
plified at  the  acetabulum,  where  several  osseous  pieces  ul- 
timately form  a  junction.  It  is  known  that  the  cotyloid 
cavitj  is  composed  originally  of  three  pieces,  and  that  the 
complete  formation  of  this  cavity  takes  place  only  at  the 
late  periods  of  osteogeny.  The  iliac  hones  are  there- 
fore liable,  according  to  this  author,  to  meet  with  obstacles 
in  their  development  al  the  acetabulum,  in  which  case 
the  head  of  the  femur — not  having  a  proper  receptacle — 
will  he  carried  upwards,  beyond  the  undeveloped  cavity. 
Now,  it  so  happens,  that  the  cotyloid  cavitj  and  the  head 
of  the  femur  have  both  been  found  progressing  to  their 
normal  development,*  or  to  have  completed  it,  in  cases  of 
this  dislocation  which  have  come  under  observation ;  and 
although  the  cotyloid  cavity  in  its  osseous  state  is  made 
up  by  the  junction  of  the  three  original  hones  of  the  OS 
innominatum,  yet,  according  to  .M.  ( 'ruveilhier.f  the  carti- 
*    Vide  Craveilhier,  Anatomie  Patholog.         +  Cruveilhior,  Anatomie  Doeoript. 


54  ETIOLOGY. 

laginous  matrix  of  the  future  hone  is  present,  continu- 
ously at  all  its  points,  at  the  same  time,  and  not  at  iso- 
lated points,  as  is  the  case  with  the  osseous  centres  from 
which  the  bones  are  ultimately  formed. 

For  myself,  I  am  not  aware  of  any  case  having  been 
met  with  in  the  foetus,  of  a  defect  or  perforation  occurring 
at  the  union  of  the  three  bones  which  constitute  the  aceta- 
bulum, and  which,  according  to  the  laws  of  centripetal 
development, — if  the  doctrine  of  arret  de  developpement  be 
true — would  be  the  point  where  a  deficiency  should  be 
found,  if  any  existed.  Even  supposing  that  in  some  in- 
stances the  head  of  the  bone  were  deprived  of  its  usual  re- 
ceptacle, by  reason  of  its  arrested  development,  those  cases 
of  dislocation,  in  which  there  were  found  to  exist  a  corre- 
lative and  normal  development  of  the  cotyloid  cavity,  as 
well  as  of  the  head  of  the  femur,  could  not  be  explained 
by  this  theory.  Besides,  there  frequently  come  under 
observation  at  the  other  articulations,  instances  of  con- 
genital dislocation,  to  explain  or  account  for  which,  M. 
Breschet's  theory  would  be  wholly  insufficient. 

IV.  Certain  Articular  Maladies  occurring  in 
the  Fcetus  during  Intra-Uterine  Life. — Pathologi- 
cal  investigations  have  taught  us  that  the  fcetus  is  liable 
to  many  affections  while  in  utero,  which  may  cause 
death,  or  terminate  in  resolution  or  health,  before  birth.* 

*   Vide  Cruvedhier's  Anatomic  Pathol. 


ETIOLOGY  . 


Prom  iliis  Tact  it  was  apparent^  ;i  rational  inference  to 
suppose,  that  the  same  morbid  cause  which,  in  the  adult, 
sometimes  produces  the  spontaneous  luxation  at  the  hip. 
might  also  in  the  foetus  determine  the  congenital  luxation 
;n  this  joint.  This  hypothesis  is  of  old  date,  and  has 
been  revived  by  some  recent  writers  with  the  parade  of 
originality.*  We  find  that  Pare,  alluding  to  the  fact 
"that  a  child  while  still  in  the  womb,  ma\  have  apo- 
stemes,  which  may  open  and  cicatrize,"  proceeds  to  say, 
"  it  may  happen  also  that  the  ligaments  which  retain 
the  hones  at  their  articulation  are  not  firm,  but  slender  and 
small  in  their  conformation,  or  are  humid  in  themselves, 
and  very  much  Inhriiied,  or  moistened  by  a  fluxion  of  pitui- 
tary and  mucous  humors,  which  relax,  and  render  soft  the 
ligaments  that  ought  to  bind  the  articulation  ;  and  hence 
the  bones  art-  easily  displaced  at  their  joints.''  Also, 
again  alluding  to  this  subject,  he  says  elsewhere,  that 
•4  the  causes  are  internal,  when  there  are  certain  humors 
and  swellings,  which  fall  upon  the  joints  in  such  abun- 
dance that  they  lubrify  and  relax  the  ligaments  which 
bind  the  bones  together,  and  throw  them  from  their 
socket."  f 

M   Parise,  who  is  the  most  strenuous  advocate  of  this 
theory,  stales,  as    his  view,  that    the  cause  of  the  ligamen- 

•  ( lri.lv  ;  Sedillol  ;  Malgaigne  ;  I 

t  Pari,  Le  quatorzieme  livre.     Edition  by  Malgaigne. 


56  ETIOLOGY. 

tons  relaxation  is  an  effusion  of  fluid  into  the  ilio-femoral 
articulation,  u  hence  results  the  expulsion  of  the  head  of 
the  femur  from  its  natural  cavity.  This  author  asks : 
"  Wherefore  should  it  not  be  admitted  that  a  few  deci- 
grammes of  fluid  can  be  secreted  in  the  articulation  of 
the  hip-joint,  when  it  is  known  that  among  the  mala- 
dies to  which  the  foetus  is  liable,  articular  dropsies  are 
of  the  most  frequent  occurrence  ?  .  .  .  .  Hereditary  pre- 
disposition in  either  case  can  be  as  well  conceived  to  exist 
in  regard  to  a  h)  drarthus,  as  to  a  vicious  development ; 
observations  prove  that  different  members  of  the  same 
family  have  been  attacked  with  dropsies,  spontaneous  lux- 
ations {luxations  spontanees),  &c.  In  this  hypothesis  it 
is  necessary  to  admit  that  the  luxation  once  produced, 
the  dropsy  disappears,  and  the  dilated  capsule  returns  to 
its  proper  dimensions  ;  sometimes,  in  young  subjects,  it 
has  been  found  more  dilated,  aud  containing  more  synovia 
than  in  the  na  ural  state  ;  but  that  it  should  have  re- 
turned to  its  nearly  natural  state  at  birth,  ought  not  to 
astonish  those  who  are  acquainted  with  the  energy  of  the 
assimilating  force,  and  the  rapidity  of  the  nutritive  revo- 
lutions appertaining   to  foetal  existence What 

renders  so  grave  the  coxalgir  affections  in  the  adult,  is  the 
extension  of  the  inflammation  to  the  neighboring  osseous 
tissue,  whence  result  caries,  suppuration,  fistula?.  Now, 
it  is  not  so  with  the  foetus,  the  cotyloid  cavity  of  which, 
as  well  as  the  head  and   neck  of  the  femur,  are  cartilagi- 


ETIOLOGY.  57 

nous  ;it  birth.     We  <l<>  n<>i  even  know  ani  fact  of  coxal- 
gia   terminating  by  abscess  in  children  under  one  or  two 
years  of  age,  although  at  this  period  ossification   is  al- 
ready advanced.''     M.  Parise,  in  the  above  remarks,  seems 
to  make  no  definite  distinction  between  articular  dropsj 
and  coxalgia,  and   to  overlook  the  different  results  which 
must  follow  from  a  simple  effusion   into  the  joint  from  a 
common   inflammatory  action,  and   that,  consequent  upon 
a  scrofulous  engorgement  of  the  tissues  of  the  articulation. 
In  his  hypothesis,  on  account  of  the  absence,  at  the  time 
of  birth,  of  any  marks  of  inflammatory  disease  in  cases  of 
luxation,  he  concedes,  that  as  soon  as  the  displacement  is 
produced,  the  effusion  must  disappear,  and  the  dilated  cap- 
sule return  to  its  natural  dimensions.     By  those  who  are 
acquainted  with  the  difficulty  of  procuring  immediate  or 
prompt  resolution  in  strumous  affections,  this  admission — 
if  the  effusion   accompanying   morbus  coxarius  be   meant 
— could  not  be  assented  to;   and  we  are  inclined   to  virw 
the  objections  urged   by  Dupuytren   against  the  theon   of 
effusion   of  fluid,  being  the  cause  of  congenital  luxations 
at  the    hip,    as  repuguant  to    the  explanation    given    by 
i\I.    Parise.      ''Many    circumstances,"    says    Dupuytren, 
••  oppose  the  supposition  that  the  origin  of  these  congeni- 
tal dislocations  can    be  the  same   as  that  of  coxalgia,  and 
first,  all  the  individuals   in  whom   the  displacement   has 
been  observed,  hail  been  in  good  health  when  thej  came 
into  the  world — a  circumstance  which  would   scarcely  ad- 

5 


58  ETIOLOGY. 

mir  of  the  supposition  that  they  had  suffered  from  a  ma- 
lady so  grave  as  that  which  induces  the  spontaneous  luxa- 
tion of  the  femur."  Moreover,  luxation  of  the  ilio-femoral 
articulation  has  been  met  with  in  the  foetus  without  the 
presence  of  any  superabundant  secretion  in  the  joint. 

V.  A  Primitive  Alteration  in  the  Nervous  Cen- 
tres.— The  theory,  which  refers  congenital  luxations  to 
this  cause,  will  be  best  considered  in  connexion  with  the 

following  : 

VI.  A  Perverted  Condition  of  the  Excito-Motor 
Apparatus  of  the  Medulla  Spinalis. — The  different 
parrs  of  the  body  are  not  all  developed  at  the  same  time. 
The  nervous  system  begins  its  evolution  primarily,  and 
seems  to  take  precedence  and  control  over  the  other  sys- 
tems. The  circulating  organs  soon  appear,  and  succes- 
sively" are  evolved  the  muscular,  osseous,  and  other  struc- 
tures. 

i  he  muscular  tissue  is  liable  to  be  sensibly  impressed 
l>v  almost  every  incident  which  can  take  place  during  ex- 
tra-uterine life,  and  its  dynamic  condition  is  constantly 
varying  even  in  a  state  of  health.  "  Comme  on  le  sait, 
ri<  n  nest  plus  variable  que  l'etat  dynamique  des  organes 
de  ce  systeme ;  dans  toute  la  duree  de  la  vie  le  moindre 
evenement  y  exerce  une  influence  plus  ou  moins  marquee. 
Une  maladie  aigue,  une  lesion  organique,  une  fievre  pas- 
sagere,  une  perturbation  temporaire  dans  les  fonctions  di- 


BTIOLOQY.  59 

gestives,  la  gestation,  des  travaus  corporels,  une  conten- 
tion d' esprit,  le  repos  prolonge,  le  seul  defaut  des  exercises 
habitueis,  ['abstinence,  les  exces,  la  simple  fraveur,  suf- 
fisent  pour  diminuer  notablement,  et  quelquefois  d'une  ma- 
niere  grave,  la  contractilite  musculaire."* 

It  is  reasonable  to  suppose  that  a  set  of  organs,  which 
have  so  extensive  a  sympathy  in  the  animal  economy, 
must,  to  a  great  extent,  either  in  health  or  disease,  be 
under  the  immediate  influence  of  the  nervous  system. 

The  pathologic  states  manifested  in  the  muscular  sys- 
tem by  means  of  which  deformities,  subluxations,  and  luxa- 
tions at  the  joints  are  induced,  are,  a  paralytic  state  of  this 
tissue  ;  and  a  morbid,  tonic,  spasmodic  retraction.  There 
is  another  cause,  sometimes  producing  deformities  at  the 
joints  through  the  muscles,  which  proceeds  from  direct 
irritation  and  the  continuance  of  a  vitiated  position,  such 
as  is  seen  to  result  from  the  influence  of  rheumatic  in- 
flammation ;  but  of  this  cause,  being  foreign  to  our  pre- 
sent subject,  it  is  unnecessary  to  speak  farther. 

The  two  causes  first  mentioned,  viz.  a  paralytic  state 
of  the  muscles,  and  a  morbid  muscular  ret  rati  ion,  although 
conditions  directly  opposite  to  each  other,  sometimes  pro- 
duce a  set  of  deformities,  having,  in  many  respects,  a 
similar  appearance.  The  modes,  however,  in  which  the 
various  deformities  are  thus  produced  differ  entirely. 

Ill    the  one  instance    the  disturbed    relation  of  the  parts 

•  Delpeoh,  De  l'Orthomorpliie. 


60  ETIOLOGY. 

is  the  effect  of  the  action  of  antagonistic  muscles, 
although  enfeebled  themselves,  overcoming  the  more  de- 
fective action  of  the  other  set  of  paralysed  muscles. 
This  is  well  exemplified  in  those  cases  of  club-foot, 
which  occur  from  a  paralytic  state  of  one  set  of  conge- 
ner muscles,  while  their  antagonists  retain  more  or  less  of 
their  activity. 

When  the  paralysis  is  entire,  this  preponderance  of 
greater  apparent  power  in  one  set  of  muscles — almost  al- 
ways of  the  flexors — over  another  set,  must  be  attributed 
to  the  inherent  contractile  tonicity,  which  is  peculiar  to  the 
muscular  system,  and  not  to  any  influence  derived  from 
the  nervous  system. 

In  the  other  instance  the  deformity,  which  may  be  ac- 
companied, or  not,  with  luxation  or  subluxation,  is  brought 
about  by  a  purely  abnormal  retraction  of  the  muscular 
tissue,  evinced  by  an  immovable  rigidity  which  pervades 
it,  and  which  results  from  an  unnatural  tonic  spasmodic 
condition  of  the  muscles.  Examples  of  deformity,  pro- 
ceeding from  this  latter  cause,  are  also  to  be  met  with  in 
cases  of  club-foot,  where  the  disposition  to  morbid  mus- 
cular retraction  is  localized  in  one  set  of  muscles,  while 
the  other  set  act  only  within  the  range  of  their  healthy 
contractile  power.  Some  cases  of  lateral  curvature  of 
the  spine,  of  torticollis,  &c,  may  also  be  referred  to  this 
cause.* 

*  Delpech  mentions  a  curious  instance,  where  a  complete  talipes  varus  was  formed 


ETIOLOGY.  o*l 

This  abnormal  muscular  retraction,  as  has  hccn  alread) 
said.  I  believe  to  be  the  result  of  a  morbid  condition  of 
the  excito-mdtor  apparatus  of  the  medulla  spinalis,  either 
conveyed  to  its  ganglionic  portion,  or  primarily  originat- 
ing in  it,  and  thence  transmitted  or  reflected  upon  thai 
portion  of  the  muscular  tissue  in  which  the  irritation  be- 
comes localized  and  manifested. 

The  muscular  tissue  is  endowed  with  the  health \  phy- 
siological property  of  alternate  contraction  and  relaxation, 
which,  whether  it  show  itself  as  the  result  of  volition,  of 
involuntary  motion,*  or  as  the  sequent  of  the  action  of 
the  excito-motor  system,  is  subordinate  to  the  influence  of 
the  nervous  centres.  Besides  this  healthy  action,  it  is 
liable  to  pathological  conditions,  which  are  manifested    by 

in  an  adult,  consecutively  to  the  paralysis  resulting  from  the  division  of  the  ischiatic 
nerve,  by  a  bullet  which  traversed  the  thigh. 

The  same  author  mentions  also  a  case  whore  club-foot  followed  the  i tinned  use 

of  an  irritating  injection  in  treating  an  abscess  situated  at  the  inferior  and  inner  part 
of  the  thigh,  and  which  was  accompanied  by  necrosis.  He  thus  describes  tin-  result  : 
'•  Pendant  cette  longue  maladic  laquelle  dura  trois  ans  entiers,  les  muscles  de  la  lace 
posterieur  de  la  jambe  Bouffranl  aympathiquement,  <>u  plutot,  par  lea  effets  de  la  par- 
ticipation du  nerl  crural  aux  inflammations  freipientes  et  profondea  de  la  i< 
interne  de  la  cuisee,  tomberent  dans  un  etat  de  contraction  tel,  que  le  pied  en  tut  en- 
traine  en  bas,  el  en  dedans,  el  deforme\  comme  dans  I'etel  du  pied-bol  le  plus  com- 
plel  el  le  plua  avance*  qu'il  soit  possible  d'imaginer."  Here  the  irritation  mual  have 
been  transmitted  to  the  muscles  producing  the  varus,  <>r  rather  it  may  have  been 

carried    to   the   medulla   spinalis,  and    thence  reflected. 

*  The  functions  of  the  Great  Sympathetic  Nerve  are  more  or  le  a  under  the 
influence  oi  the  Cerebro-Spinal  System.  ••  Tout  ganglion  Bympathiqne  commu- 
nique ou  bien  aveo  lee  deux  ordres  de  raoinee  des  nerfc  spinaux,  ou  bien  i  la  fois  avec 

des  uerl's  n  aiiini-  uioteurs  et  scnsilifs." — Lonact,  SiislSmr  .Xrirriir. 


62  I  ETIOLOGY. 

disturbance  of  its  normal  functions,  limited  and  localized 
to  a  particular  set.  of  muscular  fibres,  or  diffused  more 
or  less  throughout  this  entire  system.  Farther,  the  in- 
vestigations of  science  have  also  ascertained,  that  the  mor- 
bid state  of  the  muscular  system,  observed  during  certain 
of  its  diseased  conditions,  such  as  paralysis,  tetanus,  epi- 
lepsy, and  some  other  affections  accompanied  by  spasmo- 
dic muscular  contraction,  is  likewise  subordinate  to  a  pa- 
thologic influence,  located  primarily  in  the  cephalo-rachi- 
dian  centres,  or  conveyed  indirectly  to  them.  It  is  therefore 
a  fair  deduction,  that,  as  the  healthy  physiological  contrac- 
tion of  the  muscles  is  the  result  of  healthy  enervation, 
so  the  peculiar  condition  of  the  muscles  which  is  mani- 
fested by  the  abnormal  tonic  retraction  and  spasmodic 
shortening  of  their  fibres,  is  a  sequent  to  the  existence 
of  an  irritation,  or  of  an  altered  condition  of  some  kind  in 
the  central  nervous  system. 

There  is  also  another  function  exerted  by  the  muscles, 
which  is  peculiar  to  them,  and  independent  of  any  influ- 
ence derived  from  the  nervous  system.  This  inherent 
property  is  manifested  in  certain  cases  where  the  influence 
of  the  nervous  system  has  ceased  to  have  any  agency  ; 
the  muscles  themselves  retaining  the  power  of  tonic  con- 
tractility, as  is  exemplified  in  the  rigid  and  contracted 
state  of  the  ventricles  of  the  heart,  which  occurs  within 
an  hour  or  two  after  death.* 

*  This   inherent   tonic   muscular   contractility   is   strikingly  illustrated  by  a  case 


KTIOI.OOY.  63 

\i  the  present  dav  it  is  do  longer  a  matter  of  doubt 
that  the  foetus,  inclosed  in  its  uterine  envelopes,  is  liable 
to  many  of  the  diseases  witnessed  in  extra-uterine  exist- 
ence.41 

Many  years  ago  the  French  anatomist,  Chaussier,  from 
facts  which  came  under  his  observation,  and  probably 
from  suggestions  derived  from  the  learned  Pallet  a,  was 
induced  to  assert  that  convulsions  might  occur  to  tin 
foetus  while  still  in  the  uterus,  and  he  was  consequent!) 
led  to  refer  the  occurrence  of  certain  congenital  luxations, 
which  came  under  his  inspection,  to  a  morbid  alteration 
of  the  nervous  centres. 

The  celebrated  German  physiologist,  Rudo/phi.  enter- 
tained similar  views;  and  Delpech  has  advanced  opinions 
in  corroboration  of  the  dependence  of  congenital  malfor- 
mations and  luiations  oi  the  articulations,  such  as  the 
various  forms  of  Talipes  present,  upon  some  morbid 
affection  of  the  nervous  apparatus 

In  speaking  of  the  analogy  to  he  observed  between 
club-loot   and    certain   congenital    deformities    at    the  ilio- 

published  originally  by  Professor  Herrmann  of  Bern,  and  recorded  by  Dr.  Dew 
which  the  contractile  pi  e  uterus  three  days  after  death  was 

to  expel  twins:  "  On  the  third  day  after  the  death  of  a  young  woman,  who  •■■■        u 
herpixth  month  of  pregnancy,  the  nurse  heard  a  loud  noise  proceeding  from  the  i 
A  physician  was  immediately  Bent   for,  who  on  his  arrival   found  thai  the  dec< 
bad  brought  forth  twins,  which  were  inclosed  in  a  membrane  quite  entire,  and  i 
ill.'  [east  putrid.     The  placenta  only  appeared  t>>  have  Buffered  from  the  effects  o(  pu- 
trefaction."— Dewrex'  System  of  Midwifery. 
*  Vide  Cruveilhier's  Anatomic  l'mlml. 


64  ETIOLOGY. 

femoral  articulation,  owing  to  muscular  retraction,  the  latter 
savs :  "  II  nous  semble  difficile  de  separer  l'idee  de  ces  de- 
formites,  surtout  quand  elles  sont  parallele,  repetees  dans 
deux  articulations,  accompagnees,  comme  il  n'est  pas  rare 
de  l'observer,  de  quelques  anomalies  de  plus,  dans  les  arti- 
culations des  genoux,dans  la  disposition  des  muscles  de  la 
fesse,  de  la  cuisse,  &c. ;  il  nous  semble,  disons-nous,  diffi- 
cile de  separer  l'idee  d'une  semblable  aberration  de  l'acte 
nutritive,  de  celle  d'un  etat  anormale  anterieure  de  l'un  des 
grands  foyers  vitaux;  la  moelle  epiniere,  par  example." 

M.  Guerin  has  reproduced  this  theory,  and  has  ex- 
tended it  so  far  as  to  refer  to  an  alteration,  or  rather  to  an 
absence  of  the  whole,  or  of  a  part,  of  the  nervous  centres, 
the  source  of  that  morbid  muscular  retraction,  which  pro- 
duces the  class  of  deformities  to  which  the  foetus  is  sub- 
ject, and  which  consequently  have  been  called  conge- 
nital. He  has  carried  this  theory,  however,  to  the 
length  of  attempting  to  prove  that  there  is  always  to  be 
observed,  a  rigorous  relation  between  the  absence  of  the 
nervous  centres,  or  a  portion  of  them,  and  the  extent, 
number,  and  locality  of  the  dislocations  which  may  be 
present.  The  labors  of  Guerin  may  have  tended  to  give 
some  additional  light  on  this  theory,  but  in  his  endeavors 
to  simplify  a  point  of  science  he  has  generalized  too  far, 
and  in  attempting  to  make  facts  square  with  his  views, 
he  has  made  assertions  which  have  not  been  substan- 
tiated by  correct  observation. 


ETIOLOGY.  65 

Although  not  agreeing  with  M*  Gueria  in  regard  to 
the  invariable  antecedence  of  partial  or  total  destruction, 
or  absence,  of  the  nervous  centres,  as  the  cause  of  morbid 

muscular  retraction,  it  must  be  admitted  that  his  remarks 
are  ingenious.  As  the  point  in  question  is  one  of  scien- 
tific interest,  I  have  made  the  subjoined  extract  from  a 
memoir  read  by  him  before  the  Academy  of  Sciences  of 
Paris,  which  may  serve  as  a  summary  of  this  writer's 
ideas  upon  the  etiology  of  congenital  displacements  of 
tin1  joints,  and  among  them,  of  congenital  luxation,  at  the 
head  of  the  femur. 

"  The  observation  of  certain  monstrosities  presents  to 
us  in  a  striking  manner  the  combination  of  these  four 
orders  of  facts,  namely,  that  in  them  may  be  observed,  at 
the  same  time,  a  material  lesion  of  the  nervous  centres, 
the  retraction  of  the  totality  or  of  the  greater  portion  of 
the  muscular  system,  and  of  concomitant  luxations;  a 
rigorous  relation  between  the  seat,  the  extent,  and  the 
degree  of  the  nervous  lesion,  and  the  seat,  extent,  and 
degree  of  the  retraction  ;  and  finally,  a  relation  of  direction, 
of  extent,  and  of  degree,  between  this  retraction  and  the 
dislocations  which  it   produces. 

"I  have  already  frequent!}  shown  you,  in  certain  mon- 
strosities, the  coincidence  of  a  partial  or  total  destruction  of 
the  central  nervous  system,  with  a  retraction,  more  or  less 
general,  of  the  muscular  system,  and  the  deformation  of 
nearly  all  the   parts  of  the    skeleton,    and   particularly    of 


66  ETIOLOGY. 

the  articulations.  Here  is  a  series  of  anatomical  speci- 
mens, and  of  drawings  taken  from  specimens,  which  I 
have  not  been  able  to  preserve,  where  this  double  fact  ap- 
pears in  the  most  varied  manifestations,  from  its  most  fee- 
ble and  circumscribed  expression,  to  its  most  energetic 
and  extended.  Thus  you  can  see  in  these  facts,  cases 
where  the  alteration  of  the  nervous  centres  has  been  su- 
perficial and  transient ;  others,  where  they  have  been  par- 
tially destroyed ;  and  in  each  of  these  cases,  the  retraction 
of  a  greater  or  less  number  of  muscles,  and  of  luxations 
of  the  members,  are  met  with  simultaneously.  And 
farther,  you  see  represented  monsters  in  which  there 
is  at  the  same  time  a  complete  disappearance  of  the 
nervous  centres,  and  a  retraction  of  the  totality  of  the 
muscular  system.  I  present  to  you  in  particular  a  foetus 
anencqjhale-symele,  in  which  you  observe,  with  this  same 
retraction  of  the  muscles,  not  only  a  turning  of  the  head 
behind,  and  large  curvatures  of  the  vertebral  column,  but 
also  dislocations,  which  are  more  or  less  complete,  of  the 
principal  articulations,  such  as  the  hip-joint,  the  knees,  the 
feel,  the  shoulders,  the  elbows,  and  the  wrists. 

"  It  is  evident  then  that  the  congenital  luxations  form 
a  part  of  a  large  group  of  deformities,  springing  from  a 
common  origin,  and  that  they  are  only  special  manifesta- 
tions of  the  same  cause,  which  can  be  viewed  in  an  isolated 
manner,  only  abstractly,  and  in  relation  to  the  different 
determinate  portions  of  the  skeleton  which  they  occupy. 


ETIOLOGY.  67 

"The  anatomical  circumstances  which  accompanj  the 

two  facts,  the  existence  of  which  ice  have  just  established, 
viz.  the  absence,  more  or  less  complete,  of  the  nervous 
centres  on  one  part,  and  the  shortening  (raccourdssement ) 
of  the  muscles  on  the  other,  fully  demonstrate  that  tin 
fust  is  the  result  of  a  pathologic  process,  and  not  of  an 
arrest  in  the  development,  as  most  modern  authors  have 
thought ;  and  that  the  second  is  not  the  result  of  a  retrac- 
tion, cither  passive  or  consecutive. 

"In  the  fust  place  one  may  be  assured,  by  the  compa- 
rative study  of  those  monstrosities,  where  a  greater  or 
less  portion  of  the  brain  or  of  the  spinal  marrow  has  dis- 
appeared, that  the  absent  portion  of  the  nervous  pulp  has 
real!}  existed,  but  that  it  has  been  removed  by  means  of 
gradual  destruction.  Without  doubt,  if  we  confine  our- 
selves to  determine  this  fact  from  a  foetus  completely 
anencephalous,  it  would  be  difficult  perhaps  to  demonstrate 
rigorous!}  (he  anterior  existence  of  this  morbid  process, 
of  which  the  principal  traces  may  have  more  or  less  dis- 
appeared for  a  long  time.  But  if  you  consider  that  the 
specimens  and  the  plates,  now  under  view,  show  all  the 
degrees  of  destruction  of  the  nervous  centres  following  in 
a  decreasing  series,  which  commences  at  the  complete  dis- 
appearance of  the  encephalOn  and  the  spinal  marrow,  and 
closes  with  a  simple  lesion  of  the  membranes,  vou  will 
easily  understand   bj  what   chain  of  facts  and  of  indue- 


68  ETIOLOGY. 

tions  I  have  been  enabled  to  establish  rigorously,  the 
reality  of  this  destruction  in  those  cases,  where  we  no 
longer  find  the  union  of  all  the  characters  which  apper- 
tain to  it.  In  the  second  place,  the  retraction  of  the 
muscles  maintaining  the  articulation  displaced,  has  specific 
characters  which  enable  it  to  be  distinguished  from  the 
consecutive  retraction.  Thus  the  muscles  are  not,  as  in 
this  last  case,  shortened  merely  within  the  limits  of  the 
physiological  contraction,  and  simply  between  their  two 
points  of  insertion.  But  on  one  part  their  shortening 
surpasses  by  far  the  range  of  this  contraction  ;  we  see,  for 
example,  in  the  same  foetus  the  muscles  of  the  spine  and 
the  gastrocnemii,  reduced  to  a  third  or  a  fourth  of  their 
natural  length ;  on  the  other  hand,  they  are  in  an  extreme 
state  of  tension,  and  the  osseous  parts  upon  which  they 
are  inserted,  or  which  they  course  along,  are  often  the 
seat  of  alterations,  of  avulsions,  and  even  of  fractures,  in- 
dicating that  they  have  been  subjected  to  considerable 
violence.  Independent  of  this  tension,  these  muscles  pre- 
sent still,  by  reason  of  the  more  or  less  complete  fibrous 
transformation  which  they  have  undergone,  an  extreme 
hardness,  entirely  in  opposition  to  the  soft  consistence 
which  their  fatty  transformation  gives  to  muscles  short- 
ened consecutively.  Finally,  the  generality  of  the  re- 
traction in  a  great  number  of  cases,  and  this  remarkable 
fact,   that   it   takes    place  simultaneously   and  symmetri- 


ETIOLOGY.  69 

call \  in  the  same  articulations  <>l  both  sides,  lulK  show 
that  ii  is  not  consecutive,  and  cannoi  be  in  anj  manner 
referred  to  external  and  local  influences. 

"  Here  then  arc  already  established  two  orders  of  facts  ; 
the  existence  of  the  lesion  of  the  nervous  system,  and 
that  of  muscular  retraction,  considered  in  an  isolated 
manner.  Now,  the  relation  which  directly  unites  these  two 
facts  springs  from  the  constant  harmony  which  they  pre- 
sent in  their  different  degrees  of  manifestation,  and  in 
regard  to  the  different  portions  of  the  nervous  and  of  the 
muscular  system  which  they  occupy.  .  .  .  When 
besides  there  is  harmony,  harmony  of  seat,  and  har- 
mony of  degree,  between  the  alterations  of  the  cephalo- 
rae Indian  centre  and  the  alteration  of  the  muscles,  it  is 
impossible  not  to  admit  an  immediate  relation  between 
them.  This  is  constantly  seen  in  cerebral  pathology. 
Now.  then,  this  harmony  exists  in  the  case  which  we  are 
now  considering.  Examine  the  specimens  which  are  be- 
fore yon,  and  you  will  see  in  some  of  them,  that  tht  luxa- 
tions confined  to  the  inferior  extremities  coincide  with  the 
absence  of  the  inferior  portion  of  the  Spinal  morrow  ;  tlie 
luxation*  of  th<"  superior  extremities  with  absena  of  the 
superior  portion ;  and  the  luxation  oj  the  members  upon 
oio  side  only,  coinciding  with  the  absence  oj  one  half  oj 
the  brain.  And  here  1  can  onl\  give  \  on  rapid  indications  ; 
but  I  have  established  a  decreasing  series  of  cases  of  luxa- 
tions, subluxations,    and    pseudo-luxations,    produced    !>\ 


70  ETIOLOGY. 

muscular  retraction  in  its  different  modes  of  combination — 
a  series  in  which  one  may  discover  a  very  manifest  relation 
between  the  seat  and  the  degree  of  the  destruction  of  the 
brain  and  of  the  spinal  marrow,  and  the  seat  and  the  de- 
gree of  the  deformities  of  which  we  are  treating.  The 
specimens  placed  before  you  belong  to  this  series,  and 
suffice  already  to  establish  the  existence  of  this  rela- 
tion."* 

M.  Guerin  has  here  crowded  together  a  number  of  ge- 
neralities which  it  would  be  difficult  for  him  to  support 
by  autopsic  observations  or  physiological  facts.  In  the 
first  place  he  has  in  no  manner,  except  by  assertion, 
proved  the  anterior  existence,  and  consequent  disappear- 
ance, of  the  cerebral  structure,  or  controverted  the  doctrine, 
now  acknowledged,  which  admits  the  occurrence  of  arret 
de  develojjpement,  or,  in  other  words,  of  a  hindrance  in 
the  progress  of  the  complete  evolution  of  the  ovum, 
which  evolution  at  the  present  day,  as  regards  the  nervous 
system,  is  admitted  to  extend  in  the  progress  of  develop- 
ment from  the  periphery,  as  well  as  from  the  centre. 

In  the  second  place,  the  rigorous  relation  which  he 
has  attempted  to  determine,  as  existing  between  destruc- 
tion, partial  or  total,  of  the  encephalon  and  the  medulla 
spinalis,  and  certain  correlative  deformities,  is  proved  by 
numerous  observations  to  be  fallacious.f     It  is  a  paradox 

*  Guerin,  Memoir  read  before  the  Academy  of  Sciences, 
f    Vide  Cruveilhier,  Anatomie  Pathol. 


ETIOLOGY.  7  I 

to  s,-i\  thai  morbid  muscular  retraction  depends  upon  an 
altered  condition  of  the  nervous  centres,  and  at  the  same 
time  to  assert  thai  the  oervous  centres,  upon  the  verj  ex- 
istence of  which  the  morbid  muscular  retraction  depends, 
have  ceased  to  be  present  J  have  seen  instances  of  the 
existence  of  general  deformities  at  the  joints  similar  to 
those  mentioned  by  M.  Guerin,  and  where  the  encepha- 
lon  and  the  spinal  marrow  were  not  present;  but  I  can- 
not understand  how  these  deformities  can  be  reasonably 
referred  to  an  altered  action  of  the  nervous  centres, 
which  were  found  wanting,  and  which,  to  all  appearance, 
had  not  previously  existed.  In  those  instances  that  I 
have  seen,  there  was  no  reason  to  suppose  that  the  ner- 
vous centres  had  existed  and  afterwards  been  destroyed. 
But  supposing  they  had  disappeared  by  means  of  a  pa- 
thological process  of  destruction,  their  influence  would 
cease  with  their  disappearance,  and  the  condition  of  things 
would  then  be  the  same  as  if  no  brain  or  spinal  marrow 
had  ever  existed. 

1  see  no  way  of  accounting  for  those  deformations 
which  are  met  with  at  the  articulations  of  the  foetus, 
where  no  evidences  or  traces  of  the  cerebro-spinal  cen- 
tres are  present,  but  by  referring  them  to  the  effect  of  the 
inherent  contractile  tonicity  of  the  muscular  system  itself. 
There  would  certainly  be  an  analogy  between  deforma- 
tions thus  caused  during  foetal  life,  and  those  instances  of 
deformity  arising   from   paralysis,   having   for  their   origin 


72  ETIOLOGY. 

extensive  destruction  of  the  medulla  spinalis.  In  this 
latter  case,  the  muscular  tissue,  deprived  of  the  nervous  in- 
fluence derived  from  the  medulla  spinalis,  acts  indepen- 
dently of  the  nervous  centres  ;  and  its  inherent  contrac- 
tile tonicity  predominating,  as  is  the  case  in  health,  in 
the  flexor  muscles  generally,  determines  the  consecutive 
deformity,  in  the  direction  of  the  action  of  this  set  of 
muscles.  It  is  so  also  with  those  monstrosities  I  have 
just  mentioned,  for  the  deformities  present  in  them,  were 
generally  manifested  in  the  direction  of  the  action  of 
the  flexor  muscles. 

In  regard  to  the  other  statement,  that  the  absence  of 
the  inferior  and  superior  portions  of  the  medulla  spinalis, 
and  of  specific  portions  of  the  brain,  is  followed  by  defor- 
mities, or  by  dislocations  at  specific  articulations,  I  have 
merely  to  remark,  that  pathological  observations  do  not 
corroborate  the  assertion.  Besides  the  instances  which 
have  come  under  my  own  examination,  the  cases  reported 
by  Cruveilhier  and  others  go  directly  to  prove,  that  no 
such  relation,  as  that  upon  which  M.  Guerin  founds  his 
theory,  exists. 

If  the  total  or  partial  absence  alone  of  the  nervous 
centres  were  the  invariable  cause  of  congenital  deformi- 
ties, then  they  must  occur  as  an  invariable  sequent,  when 
this  absence  of  the  nervous  centres  takes  place,  and  in 
proportion  also  to  the  greater  or  less  disappearance  of  the 
nervous  substance.     In  other  words,  there  could  be  no 


ETIOLOGY.  73 

congenital  displacements  without  absence  of  some  portion 
of  the  central  nervous  system,  nor  could  there  be  any 
foetal  anencephalous  monstrosities,  without  the  existence 
of  numerous  luxations  <>r  subluxations. 

As  soon  as  the  correlation  of  circumstances,  reported 
by  M.  Guerin,  is  found  to  be  at  variance  with  facts,  the 
generalization  he  has  adopted,  must  be  pronounced  falla- 
cious. Now,  anencephalous  foetal  monsters  are  to  be 
met  with,  in  which  no  dislocations  of  the  articulations  are 
present,  and  it  is  no  uncommon  event  to  see  congenital 
dislocations  attributable  to  muscular  retraction — not  only 
of  the  hip-joints, — but  also  of  many  of  the  other  articula- 
tions, without  any  palpable  absence  of  the  nervous 
centres. 

Thus,  in  those  cases  I  have  to  relate  hereafter,  and 
from  which  I  have  had  the  drawings  taken,  there  was  no 
absence  of  the  nervous  centres  apparent,  nor  in  the  cases 
related  by  Palleta  and  Dupuvtren,  is  the  absence  of  any 
portion  of  the  spinal  marrow  or  of  the  encephalon  al- 
luded to. 

The  physiology  of  the  nervous  system,  and  its  influ- 
ence over  muscular  contraction,  will  nevertheless  induce 
the  inquirer  to  look  to  the  centres  of  this  system  as  the 
source,  whence  is  radiated  the  pathologic  influence,  which 
manifests  itself  in  the  muscles,  in  the  form  of  morbid 
muscular  retraction,  and  upon  which  probably  depend 
many  congenital  dislocations,  and  among  them  the  dislo- 

6 


74  ETIOLOGY. 

cation  of  the  head  of  the  femur  from  the  cotyloid  cavity. 
This  doctrine  is  the  most  philosophical  among  the  vari- 
ous theories  which  have  been  brought  forward  to  account 
for  the  displacement,  and  seems  to  be  corroborated  by 
physiological  induction. 

The  nervous  centres  of  the  cerebro-spinal  axis  are 
composed  essentially  of  a  grey  or  cineritious  matter, 
which  forms  the  ganglionic  part,  and  the  white  fibrous  or 
tubular  structure,  which  is  more  or  less  intimately  con- 
nected with  the  former.  The  physiology  of  the  present 
day  teaches  us,  that  the  grey  material  or  ganglionic 
structure,  is  the  source  from  which  enervation  emanates, 
and  that  the  fibrous  or  white  matter  is  the  conducting 
medium,  by  means  of  which  the  various  functions  of 
sensation  and  motion,  whether  voluntary,  involuntary,  or 
consensual,  are  carried  on.  The  cephalo-rachidian  mass 
is  formed  by  an  aggregation  of  the  fibres  of  the  white 
tubular  nervous  substance,  into  a  large  nervous  cord, 
composed  of  several  columns  or  strands,  which  ascend, 
under  the  name  of  the  medulla  spinalis,  through  the  osseous 
canal  formed  by  the  several  vertebrae.  Most  of  the 
fibres  of  these  strands,  emerging  from  the  medulla  oblon- 
gata, traverse  successively,  from  behind  forwards, 
the  pons  varolii,  the  tubercula  quadrigemina,  the  optic 
thaiami,  and  the  corpora  striata,  and  are  then  radiated 
in  the  cerebral  lobes ;  while  some  pass  to  the  cere- 
bellum.    Interspersed  in    different  directions,    and    bear- 


ETIOLOGY.  75 

ing  certain  anatomical  relations  to  the  white  fibrous 
structure,  the  vesicular  grej  matter  is  found,  forming  the 
several  ganglionic  centres,  which,  in  conjunction  with 
this  white  fibrous  structure,  are  subservient  to  the  per- 
formance  of  the  several  functions  peculiar  to  the  cerebro- 
spinal system.  These  various  fundamental  parts,  besides 
the  decussations  which  take  place  in  certain  directions,  are 
more  intiinatelj  connected  by  another  set  of  while  fibres, 
which  are  called  commissures,  and  which  run  in  such  a 
direction  as  to  form  various  communications  between 
the  different  parts  of  the  brain,  hut  chiefly  between  the 
analogous  organs  of  one  side  with    those  of  the  other. 

Commencing  above,  we  find  the  cerebral  hemispheres 
covered  h\  the  hemispherical  ganglia,*  holding  a  close  re- 
lation with  intelligence,*  and  other  psychological  pheno- 
mena. These  lie  above  the  grey  matter  of  the  corpora 
striata  and  of  the  optic  thalami,  as  well  as  above  the  ganglia 
which  arc  in  immediate  connexion  with  the  organs  of 
special  sense;  the  medulla  oblongata  furnishes  ganglionic 
centres  for  the  movements  of  respiration,  mastication,  and 
deglutition  ;  from  the  upper  portion  of  the  medulla  oblon- 
gata the  cerebellum  shoots  oflf,  supplied  with  its  cineri- 
tious  mailer;  and  lastly,  a  continuous  track  of  grey  OF 
cineritious  matter,  analogous  to  the  chain  of  the  locomo- 
tive ganglia  in  the articulata,  is  found  extending  the  whole 

■    Hemispherical  ganglion  i>  the  term  applied  by  Mr.  Solly  i"  the  oineritioua  mai- 
tor  capping  the  een  bra!  hemispheres. 


76  ETIOLOGY. 

length  of  the  medulla  spinalis,  invested  by  the  white  fibres 
of  the  tubular  structure. 

Besides  contributing  to  the  performance  of  certain  other 
functions,  most  of  these  various  cineritious  deposits  or 
ganglia  are  the  centres  of  a  class  of  exceedingly  important 
phenomena  in  the  animal  economy,  which  in  lat- 
ter times  have  been  denominated  the  excito-motory 
or  reflex  functions  of  the  nervous  system*  Certain 
reflex  movements  are  admitted  by  some  modern  physiolo- 
gists to  emanate  from  the  ganglia  contained  in  the  cra- 
nium ;  but  the  medulla  spinalis  is  undoubtedly  the  centre 
of  the  excito-motor  functions  manifested  in  the  organs 
of  locomotion. 

The  peculiarity  of  the  healthy  nervous  action,  termed 
reflex,  consists  in  the  occurrence  of  muscular  movements  or 
contractions,  as  the  sequent  to  impressions,  not  involving 
sensation  or  consciousness,  and  taking  place  through  the 
medium  of  a  set  of  incident-excitor  nervous  fibres,  and 
another  set  of  reflex-motor  nervous  fibres,  both  of  which 
are  in  connexion  with  the  cineritious  ganglionic  mass, 
acting  as  the  centre  of  the  excito-motor  circuit. 

Examples  of  muscular  movement,  entirely  independent 
of  volition  or  of  sensation,  are  presented  in  the  experi- 
ment upon  a  frog  which  has  been  decapitated ;  the  spinal 
marrow  being  left  uninjured.      In  such  a  case,  if  the  pat 

*  This  class  of  motor  functions,  independent  of  sensation,  was  known  to  Pro- 
chaska.  The  writings  of  Dr.  Marshall  Hall  and  of  Miiller  have,  however,  greatly 
elucidated  this  subject  in  more  recent  times. 


ETIOLOGY.  77 

of  the  frog  be  touched  with  citric  acid,  or  any  other  suf- 
ficientrj  powerful  irritant,  the  animal  will  evince  muscular 
contraction  of  the  limb,  as  if  from  volition. 

The  medulla  spinalis,  viewed  as  the  centre  of  the  spinal 
excito-motor  system,  offers  other  points  for  consideration 
in  regard  to  its  extensive  connexions. 

The  thick  cord  which  composes  this  portion  of  the 
cerebro-spina]  axis,  is  distinctly  a  double  tract,  although 
united  by  numerous  commissural  bands,  and  is  divided 
into  two  equal  parts  by  an  anterior  median  and  a  poste- 
rior median  fissure.  Each  half  is  again  subdivided  into 
two  columns — a  posterior  and  an  antero-lateral  column — 
forming  the  strands  for  sensation,  and  for  motion. 

On  each  half  of  the  spinal  column  three  furrows  are 
observed  ,  one,  called  the  posterior  intermediate  furrow, 
which  commences  on  the  outside  of  the  small  protube- 
rance adjoining  the  nib  of  the  calamus  scriptorius,  and 
terminates  towards  the  middle  of  the  dorsal  portion  of 
the  medulla  spinalis  ;  another,  situated  a  little  outside  of 
the  preceding,  called  the  postero-lateral  furrow,  extend- 
ing the  entire  length  of  the  spinal  cord  ;  and  the  third, 
extending  the  same  length,  called  the  antero-lateral  furrow, 
situated  a  little  external  to  the  anterior  median  fissure. 
From  these  last  two  lateral  furrows,  on  each  side,  spring 
the  several  spinal  nerves,  which  are  distributed  to  the 
organs  of  locomotion.     All  the  spinal  nerves*  emanate 

*  The  lir.-t   spinal  or  sub-occipital  nerves  sometimes  arino  by  a  single  B8t  <>t  FOOtay 
from  the  motor  columns. 


78  •  ETIOLOGY. 

from  the  cord  by  two  roots  ;  an  anterior,  subservient  to 
motion,  which  is  seen  to  emerge  from  the  antero-lateral 
furrow,  and  a  posterior,  subservient  to  sensation,  which  is 
implanted  in  the  postero-lateral  furrow.  Upon  the  poste- 
rior root,  at  the  intervertebral  foramina,  a  ganglion  is 
formed,  immediately  external  to  which,  the  two  roots  in- 
terlace, and  unite  into  one  cord,  whence  result  the  several 
branches  which  pass  onwards  to  their  ultimate  distribution. 
In  tracing  the  roots  of  the  spinal  nerves  into  the  sub- 
stance of  the  medulla  spinalis,  we  find  that  each  root 
becomes  connected  by  some  of  its  fibres  with  the  peaks 
which  the  cineritious  matter  of  the  cord  forms,  in  approxi- 
mating the  antero-lateral  and  postero-lateral  furrows  on 
each  side.  The  course  and  direction  which  the  other 
nervous  fibres  take,  after  their  junction  with  the  cord,  has 
not  been  clearly  demonstrated  in  man,  although  from 
physiological  analogy  they  no  doubt  become  continuous 
with  the  white  fibres  of  the  spinal  strands,  and  ascend- 
ing with  them,  communicate  with  the  encephalon.* 

*  Vide  Grainger,  Observations  on  the  Structure  and  Functions  of  the  Spinal 
Cord. 

The  anatomical  connexion  between  the  spinal  cord  and  the  roots  of  the  rachidian 
nerves  is  a  point  of  much  interest,  both  in  a  medical  and  chirurgical 
point  of  view.  From  dissections  made  by  Mr.  Newport  of  some  of  the 
Articulata,  it  would  appear  "  that  of  the  fibres,  constituting  the  roots,  by  which 
the  nerves  are  implanted  in  the  ganglia  of  the  ventral  cord,  some  pass  into  the  vesi- 
cular matter  of  each  ganglion,  and  aftei  coming  into  relation  with  its  vesicular  sub- 
stance, pass  out  again  on  the  same  side  ;  while  a  second  set,  after  traversing  the  vesi- 
cular matter,  passes  out  by  the  trunks  proceeding  from  the  opposite  side  of  the  same 


Etiology,  79 

From  this  cursory  statemeni  it  will  be  seen  thai  the 
spinal  column,  besides  the  component  parts  aecessarj  for 
the  transmission  of  sensation  and  of  voluntan  motion, 
has  in  its  composition  the  structural  elements  necessary 
for  the  performance  of  the  excito-motor  functions.  Thus, 
there  arc  the  longitudinal  whiir  fibres  ascending  towards 
the  encephalon;  next,  invested  by  these,  is  found  the 
crescentic-shaped  grey  ganglionic  mass;  and  in  direct 
connexion  with  this  cineritious  nervous  pulp,  arc  the 
fibres  appertaining  to  the  double  roots  of  the  .spinal 
nerves,  some  of  which  fibres  join  the  ascending  strands, 
and  subserve  volition ;  while  others  terminate  more 
abruptly,  and  are  subservient  to  the  incident -excitor  and 
reflex-motor  action  of  the  medulla  spinalis. 

It  is  a  well  ascertained  fact  that  the  posterior  root  of 
the  spinal  nerves  is  the  structure,  by  means  of  which 
impressions  are  conveyed  centripetally  to  the  nervons 
centres,  and  also  that  the  anterior  root  is  subservient  to 
the  excentric  or  motor  functions  which   take  place  in   the 

ganglion  ;  and  a  third   Bel   runs  along  a  portion  of  the  cord  which  connects  the  gan- 
glia nt'  different  segments,  and  enters  the  nervous  trunks  thai   issue  from  them,  at  a 
distance  of  one  or  more  ganglia  above  or  below.     Thus  it  appears,  thai  an  impression 
conveyed  by  an  afferenl  fibre  to  any  ganglion,  ma]  ex<  ite  a  motion  in  the  muse! 
the  Bame  Bide  of  its  own  segment  ;  or  in  those  of  the  opposite  si>lo  ;  or  in  those  oi 
ments  at  a  greater  or  [ess  distance,  according  to  the  poinl  at  which  the  efferent  ; 

leave    tin-   cord."      This    arrangement     has    not    hitherto    been     discovered     m    man, 

but   physiological    facta  would   induce  the  belief  of  a   similar  arrangement,  which 

would  account  anatomically  for  man]  of  the  complex  phenomena  of  reflex  a< i. — 

Vide  Carpenter'*  Physiology,  and  Newport,  in  Philosophical  Trah9oction$,fm  16  19 


80  ETIOLOGY. 

muscles,  as  the  result  of  impressions.  These  facts  are 
determined  by  what  follows  upon  the  section  of  the  two 
roots  of  the  spinal  nerves.  Thus,  after  the  section  of 
the  posterior  root,  if  an  irritant  be  applied  to  the  remote 
divided  end,  there  is  no  manifestation  of  sensation  ;  while, 
if  it  be  applied  to  the  divided  end  near  to  the  cord,  the 
animal  will  show  evident  symptoms  of  pain.  The  con- 
trary effect  is  observed  when  the  anterior  root  is  divided  ; 
in  that  case  muscular  contractions  follow  the  application 
of  the  irritant  to  the  remote  divided  extremity  of  the 
nerve,  while  no  manifestation  is  made  when  the  stimulus 
is  applied  to  the  divided  end  next  to  the  cord. 

Here  we  have  an  afferent  set  of  fibres  which  convey 
impressions  to  the  central  nervous  system,  and  another 
set  of  efferent  fibres,  conveying  thence  the  motor  impulse 
to  the  muscles.  There  is  no  doubt  that  many  of  the 
sensations  and  manifestations  of  voluntary  motion  ascend 
to,  and  descend  from,  the  encephalon,  along  the  spinal 
strands  ;  but  there  is  another  set  of  muscular  motions 
which  are  not  attended  by  consciousness,  and  are  wholly 
independent  of  the  will.  With  the  exception  of  those 
involuntary  movements  depending  upon  the  influence  of 
some  of  the  inter-cranial  cineritious   masses,*  the  class  of 

*  The  reflex  functions  of  the  medulla  oblongata,  which  is  viewed  merely  as  a  pro- 
longation of  the  medulla  spinalis,  are  comprised  in  the  spinal  excito-motory  system, 
a;  recogm-ed  by  Dr.  Marshall  Hall.  But  Miiller  has  gone  further,  and  applied  the  prin- 
ciple of  reflexion  which  takes  place  from  the  sensorial  nerves  upon  the  motor  nerves, 
through  the  medium  of  the  encephalic  ganglionic  masses,  to  the  theory  of  all  automa- 
tic movements  consequent  upon  sensations. —  Vide  Miiller,  Physiolog.  Nerv.  Syst. 


ETIOLOGY.  81 

involuntary  movements  are  dependent  for  their  exercise 
upon  the  medulla  spinalis.  The  grej  cineritious  mass  of 
the  spinal  cord  is  the  centre  or  source  of  enervation  of 
these  movements  which  are  unconnected  with  volition; 
and  those  fibres  of  the  various  nerves  that  are  in  direct 
connexion  with  it,  are  the  Lncident-excitor  and  re  Ilex- 
motor  conductors,  which,  by  their  junction  with  the  grey 
ganglionic  mass  of  the  medulla  spinalis,  form  the  true 
spinal  excito-motory  system. 

The  experiment  of  the  decapitated  frog,  already  alluded 
to,  will  serve  to  illustrate  this  principle.  The  head  heing 
removed,  the  iufluence  of  volition  is  at  an  end.  But 
v\  hen  the  pat  is  irritated  by  the  application  of  an  ignited 
match,  or  any  other  efficient  irritant,  muscular  contraction 
immediately  takes  place,  and  an  apparently  voluntary 
effort  is  made  to  escape  from  the  effects  of  the  irritant. 
If,  however,  the  integrity  of  the  spinal  marrow  he  de- 
stroyed  l>\  passing  a  wire  down  the  vertebral  canal  of 
the  animal,  no  irritant,  however  powerful,  applied  to 
its  foot  or  its  cloaca,  will  excite  any  muscular  movement 

Again,  as  is  observed  in  the  human  subject,  in  cases  of 
accidental  fracture  of  the  vertebra-,  with  serious  lesion  of 
tin'  spinal  marrow  of  the  dorsal  region,  both  voluntary 
motion  and  sensation  are  entirely  destroyed  in  all  the 
parts  below  the  point  of  the  solution  of  continuity. 
Notwithstanding  the  isolation  of  the  interior  portions  of 
the  boil\   from    the    encephalon,  reflex   movements  can   be 


82  ETIOLOGY. 

excited  in  the  limbs  by  irritants  applied  to  the  feet,  the 
anus,  or  any  other  part  of  the  surface  below  the  injured 
point.  Here  we  have  the  manifestation  of  the  normal 
reflex  action  of  the  spinal  cord.  The  excito-motor  circle 
is  brought  into  play  by  the  afferent  conducting  fibres, 
which  convey  the  impression  to  the  ganglionic  centre. 
Thence,  by  means  of  the  efferent  set  of  fibres,  the  impres- 
sion is  again  transmitted  to  the  locomotor  muscles,  which 
consequently  are  thrown  into  a  state  of  contraction. 

The  examples  of  the  influence  of  the  healthy  excito- 
motory  functions  of  the  spinal  cord  over  certain  actions  of 
the  muscular  system  are  numerous,  but  it  is  unnecessary 
at  present  to  draw  upon  them  for  further  illustration. 
Enough  has  been  said  to  exhibit  the  principle  upon 
which  a  large  class  of  normal  muscular  phenomena 
depends. 

Notwithstanding  the  assertion,  already  commented  upon, 
of  M.  Guerin,  that  absence  of  the  brain  and  spinal  mar- 
row are  the  essential  antecedents  to  the  production  of 
congenital  dislocations,  I  am  inclined  to  believe  that  their 
origin  must  be  accounted  for  in  a  different  manner; 
and  that  derangement  of  the  functions  of  the  spinal 
excito-motor  system  must  be  regarded  as  the  true  cause 
of  those  congenital  dislocations,  which  are  the  result  of 
morbid  muscular  spasmodic  contraction ;  and  it  is  to  that 
source  I  would  attribute  the  dislocation  of  the  hip-joint 
occurring  to  the  child  while  still  in  utero. 


ETIOLOGT. 

The  peculiar  functions  of  the  excito-motor  apparatus, 
like  the  functions  of  the  other  portions  of  the  nervous 
system,  may  become  perverted  or  disturbed  by  pathologi- 
cal influences,  ft  is  probable  that  all  spasmodic  convul- 
sive muscular  movements,  taking  place  in  the  different 
parts  of  the  body,  originate  from  the  same  principle, 
whether  from  reflex  action  of  the  spinal  marrow,  of  the 
medulla  oblongata,  or  of  the  nervous  apparatus  in  con- 
nexion with  the  encephalic  ganglia. 

Examples  of  this  perverted  function  of  reflex  action 
are  met  with  in  the  symptomatic  phenomena  which  are 
to  he  observed  in  tetanus,  hydrophobia,  epilepsy,  &c. 

It  is  to  a  morbid  condition,  then,  of  th^ reflex  function 
of  the  spinal  cord  that  the  peculiar  tonic  spasmodic 
niraction  of  the  muscles  should  he  referred,  which,  either 
during  intra-uterine  or  extra-uterine  life,  is  sometimes  seen 
to  pervade  the  entire  muscular  system,*  or  at  others  to  show 
itself,  by  attacking  in  an  isolated  manner,  a  single  set  of 
muscles  only,  or  within  still  narrower  limits,  by  being  con- 
fined to  a  few  muscular  fasciculi. 

When  the  antagonistic  muscles  are  equally  affected,  so 

*  A  case  was  shown  me,  while  in  London,  by  Mr.  Tamplin,  the  eminent  surgeon 
of  the  Orthopaedic  Institution,  which  exhibited  in  a  remarkable  decree  this  morbid 
tonic  spasmodic  muscular  retraction.  All  the  muscles  "f  locomotion  were  aflected, 
bo  thai  the  trunk  and  limbs  of  the  patient,  a  lad  a^k-A  about  fourteen,  wew  in  ■ 
<>f  absolute  rigidity.  The  differenl  Bets  of  muscles,  however,  in  this  instance  • 
equally  aflected,  bo  thai  the  flexors  and  the  extensors  antagonized  each  other,  and 
[uently  there  was  no  deformity  of  the  articulations. 


84  ETIOLOGY. 

that  an  equilibrium  is  still  maintained,  the  relations  of  the 
articulating  surfaces  of  the  joints  to  each  other  are  not 
disturbed ;  but  in  those  instances  where  the  retractive 
spasmodic  influence  appears  to  be  particularly  concen- 
trated upon  one  set  of  congener  muscles,  luxations  or  sub- 
luxations are  likely  to  occur. 

Muscular  spasmodic  retraction,  resulting  from   a  per- 
verted state  of  the  excito-motor  apparatus,  may  take  place 
from  irritation,  whether   localized  at  the  periphery,  or  at 
some  point  along  the  course   of  the   afferent  or  incident- 
excitor  nervous  fibres ;  or  it  may  show  itself,  when  the 
irritation  is  localized  in  the  central  ganglionic  mass  itself 
of  the  spinal  co^l ;  or  it  may  result  from  this  nervous  centre 
being  in   a  state  abnormally  susceptible  to  impressions. 
In  this  latter -condition,  a  morbid  train  of  reflex  muscular 
movements  is  put  into  operation  upon  the  occurrence  of 
some  trivial  irritation  of  the  afferent  nervous  fibres,  which 
are  proceeding  towards  the  ganglionic  centre  of  the  cord. 
From  the  ganglionic  centre,  the  morbid  impression  is  ulti- 
mately transmitted  to  the  muscles,  through  the  agency  of 
the  reflex-motor  nervous  fibres. 

Whether  the  irritation  is  primarily  located  in  the  central 
grey  substance  of  the  medulla  spinalis,  or  is  conveyed 
there  by  ni£ans  of  the  incident-excitor  fibres — whose 
function  it  is  to  convey  impressions  to  it — I  believe  it  is 
absolutely  necessary  that  this  ganglionic  focus  of  enerva- 
tion  should  be    morbidly   impressed,  before    the   muscles 


ETIOLOGY.  85 

supplied  l>\  the  reflex-motor  nervous  fibres  can  be  thrown 
into  convulsn  e  spasm. 

I   should  say,  then,  that  the  congenital  displacements, 

occurring  at  the ilio-femoral  articulation,  result  from  active 
morbid  muscular  retraction  ;  that  morbid  muscular  retrac- 
tion itself  is  to  be  traced  to  a  morbid  condition  of  the 
central  ganglionic  mass  of  the  cord  ;  and  that  this  patho- 
logical condition  is  either  located  in  the  ganglionic  mass, 
or  convened  thither  by  the  incident-excitor  nervous  influ- 
ence of  the  excito-motor  apparatus  of  the  medulla  spinalis. 

When  the  shallow  condition  of  th"  acetabulum,  and 
the  flexed  position  of  the  thighs  of  the  foetus  in  utero — 
causing  the  head  of  the  femur  to  press  continually  against 
the  depressed  lip  of  the  acetabulum — are  considered,  it 
will  not  be  difficult  to  comprehend  the  facility  with 
which  the  head  of  the  femur  may  escape  from  the  coty- 
loid cavity,  if  the  glutei  muscles  and  the  other  pelvi- 
leinoral  muscles  are  thrown  into  a  state  of  spasmodic  mus- 
cular retraction.* 

It  is  probable,  in  congenital  dislocation  of  the  hip-joint, 
that  the  cineritious  substance  of  that  portion  of  the  me- 
dulla spinalis,  in  direct  relation  with  the  reflex-motor 
nervous  fibres  which  are  distributed  to  the  glutei  and  the 
other  pelvi-femoral  muscles,  is  the  implicated  point,  from 
which  the  morbid  impressions  radiate,  that  ultimately 
affect  the  muscular  tissue. 

•  vat  tlate  hi. 


86  ETIOLOGY. 

The  numerous  incident-excitor  nervous  fibres  which 
are  connected  with  the  cord,  the  extensive  communications 
existing  between  the  various  portions  of  the  nervous 
system  by  means  of  the  longitudinal  fibres  of  the  spinal 
strands  and  of  tbe  commissures,  and  the  decussa- 
tions which  take  place  in  certain  directions,  will  serve  to 
explain  the  facility  with  which  impressions,  arising  from 
irritation  located  at  a  distance,  may  be  conveyed  towards 
certain  points  of  the  ganglionic  portion  of  the  nervous 
centres. 

What  this  particular  source  of  irritation  or  pathologic  ac- 
tion— the  necessary  antecedent  of  morbid  muscular  retrac- 
tion— may  be,  it  is  not  easy  to  determine  strictly.  W  hether 
it  amounts  to  inflammation;  or  to  ramollissement ;  or  to 
vascular  congestion  of  the  cineritious  matter,  or  of  the 
white  structure  in  contiguity  with  it;  or  simply  to  what 
is  called  nervous  irritation,  caused  by  pressure  or 
otherwise ;  or  whether  it  depends  upon  an  abnormal 
accumulation  of  nervous  fluid,  •  which  by  some  has 
been  supposed  to  be  as  nocuous  in  regard  to  the 
nervous  substance,  as  the  accumulation  of  biood  in  an 
inflamed  tissue  is  to  the  several  structures  of  the  body  ; 
or  whether  from  some  poisonous  condition  of  the  biood — 
the  nervous  tissue  bathed  by  this  fluid  as  it  circulates 
becoming  morbidly  impressed  ; — or  whether  an  imperfect 
development  of  a  portion  of  the  medulla  spinalis,  or  an 
atrophy  of  it,  be  essential,  in  producing  tliis  disturbance  of 


ETIOI.OOV.  87 

the  exsito-motor  apparatus,  are  points  which  can   onlj 
with  grea!  difficulty  be  decided  in  a  rigorous  manner. 

A.cute  spasmodic,  muscular  affections  ma\  have  various 
remote  or  ultimate  causes  for  their,  production,*  and  ii  is 
not  improbable  thai  the  sources  of  irritation  above  enu- 
merated may  at  times  act  singly  or  conjointly,  in  arousing 
the  more  chronic  form  of  spasmodic  contraction,  which 
shows  itself  in  a  tonic  rigidity  and  retraction  of  the  mus- 
cular tissue. 

Pathological  facts,  then,  will  not  sustain  the  theory, 
which  supposes  mere  ahsence  of  the  nervous  centres  to 
be  the  invariable  cause  of  the  spasmodic  muscular  retrac- 
tion, upon  which  congenital  displacements  depend, 
Neither  will  facts  derived  from  physiology  induce  this 
belief.  Thus,  if  M.  Guerin's  assertion  were  true,  that  all 
anencephalous  foetal  monsters  present  numerous  luxations 
throughout  the  body,  and  that  these  are  in  proportion  to 
the  quantity,  and  in  relation  to  the  part  of  the  brain,  which 
is  wanting,  we  should  be  led  to  believe  that  convulsions 
and  spasmodic  muscular  movements  would  be  produced 
by  removal  of  the  brain  from  an  animal  in  the  experi- 
ment of  vivisection. 

That  this  is  not  the  case  any  one  may  determine  bj 
removing,  for  example,  the  cerebral  lobes  of  a  pigeon,  leav- 

mplee  of  this  kind  are  the  spasmodic  muscular  contractions  which  follow 
tin-  exhibition  of  Strychnine, — occur  in  Traumatic  Tetanus, — in  Idiopathic  Tetanus, 
— result  from  the  rinu  of  Hydrophobia,  &c. 


88  ETIOLOGY. 

ing,  however,  the  nervous  apparatus  of  respiration,  and  of  the 
other  animal  functions,  intact.  The  animal  thus  treated, 
not  only  manifests  no  symptoms  of  convulsive  muscular 
movements,  but  the  muscles  of  respiration  act  normally 
for  several  days,  and  even  the  functions  of  walking  and 
flying  can  be  induced  by  pushing  the  animal  onward,  or 
by  throwing  it  upward  in  the  air ;  no  evidences  of  spasm 
or  of  irregular  muscular  action  being  apparent. 

After  the  examination  of  these  various  theories,  I  shall 
conclude  these  etiologic  remarks  by  saying,  that  it  appears 
most  in  accordance  with  science  to  refer  the  muscular  spas- 
modic retraction,  upon  which  congenital  dislocation  of  the 
head  of  the  femur  from  the  cotyloid  cavity  depends,  to  a  per- 
verted condition  of  the  excito-motor  apparatus  of  the  me- 
dulla spinalis,  and  more  especially  of  that  portion  of  it 
which  is  in  direct  relation  with  the  reflex-motor  nervous 
fibres,  distributed  to  the  pelvi-femoral  muscles  surround- 
ing, and  in  connexion  with,  the  ilio-femoral  articula- 
tion. 


EXPLANATION  OF  PLATE   No.   [V. 

ioi  view  of  Double  Congenital  Di  location    of  th<    Head  of  both   I 
upon  the  dorsum  of  the  Ilium. 

6.  Trochanter  Major. 

,-.  ( )-  Coccygis  tilted  upwards  and  backwards. 

d.  The  Lumbar  Region  curved  forwards  by  the  traction  of  the  Psoas  Mus< 

j.  The  fold  between  the  buttock  and  thigh. 

/".  The  Feel — directed  forwards. 

The  case  from  which  plates  Nos.  i.,  ii.,  and  iv.,  wore  taken,  came  under  mj 
i  while  I  was  temporarily  in  London. 
Irawing  was  taken  by  Mr.  Kearnej  [lent  draughtsman,  attached  tu 

St.  Thomas'  Hospital  as  Curator  of  thi  museum. 

ons  of  that  hospital  expressing  ad  the  case,  as  they  were 

not  acquainted  with  this  form  of  dislocati f  the  hip-joint,  I  sent  the  lad  i''>r  their 

examination.     Mr.  South,  our  of  the  eminent  surgeons  attached  to   St.  Thon 
urred  s\itii  me  in  my  d  i  te  to  permit  a  full  lenj 

I       iorti  I  this  ca  e  in  th    I 
1844,  an  abstract  of  which  will  be  found  in  the  following  chapter. 


91 


CHAPTER  IV. 

SYMPTOMATOLOGY     OF     CONGENITAL     DISLOCATION     OF    THE 
HEAD    OF    THE    FEMUR    UPON    THE    ILIUM. 

The  symptoms  accompanying  congenital  dislocations 
of  the  hip-joint  necessarily  vary  in  intensity,  according  to 
the  age  of  the  individuals  that  may  he  thus  affected,  or 
the  progress  which  the  malady  may  have  made  towards 
its  extreme  development.  In  the  infant  it  may  readily  he 
supposed  that  the  pathognomonic  signs  are  not  so  dis- 
tinctly marked  as  in  after  life,  when  a  combination  of 
causes,  such  as  the  superincumbent  weight  of  the  body 
acting  during  progression,  the  physiological  contraction  of 
the  muscles,  and  their  imperfect  development  consequent 
upon  their  altered  action  and  relations,  have  been  exerting 
their  influence  for  many  years.  The  evidences  of  the 
existence  of  this  displacement  are,  however,  sufficiently 
characteristic,  at  all  ages,  to  enable  the  practitioner  ac- 
quainted with  this  subject  to  avoid  making  an  erroneous 
diagnosis. 

In  describing  the   displacement   at  the   hip-joint,  now 


92  SYMPTOMATOLOGY. 

under  consideration,  which,  if  not  arrested  or  remedied  in ' 
the  early  stages  of  life,  is  generally  progressive  in  its 
course,  I  have  preferred  to  delineate  the  symptoms  as  they 
are  presented  towards  the  period  of  puherty  or  adoles- 
cence, presuming  that  the  general  characters  when  once 
known,  as  they  appear  in  a  marked  degree  of  develop- 
ment, could  not  easily  be  mistaken  when  met  with  in  a 
form  less  distinctly  defined. 

As  has  previously  been  remarked,  the  head  of  the 
femur  may  be  dislocated  from  the  acetabulum  in  several 
directions.  We  shall  pass  over,  however,  those  variations 
which  occur  in  monstrosities  only,  and  direct  our  atten- 
tion to  that  form  of  displacement  which  is  met  with  in 
practice,  and  in  which  the  head  of  the  femur  is  found 
upon  the  ilium,  immediately  above  and  behind  the  coty- 
loid cavity,  or  completely  upon  the  dorsum  of  the  ilium, 
according  to  the  stage  at  which  the  examination  of  the 
luxation  may  be  made. 

The  congenital  dislocation  upwards,  and  outwards 
upon  the  ilium,  is  found  at  times  to  be  present  simulta- 
neously in  the  same  individual,  on  both  sides.  In  other 
instances  the  luxation  exists  on  one  side  only. 

The  changes  which  have  taken  place  in  cases  of  this 
dislocation  can  be  best  studied  by  observing  the  malfor- 
mations which  are  seen  upon  inspecting  the  patient 
when  entirely  stripped  of  clothing ;  by  tracing  the  altered 
relations  of  the  component  parts  of  the  ilio-femoral  arti- 


81  MPTOM  ITOLOG1  ■  93 

dilation,  discoverable  by  manual  examination;  and  by 
regarding  die  functional  disturbance  occurring  at  the 
joint  itselfj  in  reference  to  its  various  movements. 

Double    Congenital    Dislocation   of    the    Femur 

i  pon  the  i:.M  m. — When  the  dislocation  is  on  both  sides, 
as  is  mosl  frequently  the  case,  the  deformity  is  often 
symmetrical.  Both  of  the  inferior  extremities  m;i\  have 
the  same  development  and  length,  but  the  body  being 
generally  well  formed,  a  marked  disproportion  is  seen  to 
exist  between  the  relative  height  and  size  of  the  trunk, 
and  the   apparent  shortness  of  the  lower  limbs. 

Upon  viewing-  an.  adult  person  while  in  the  erect  pos- 
ture, affected  with  this  kind  of  double  luxation  of  the 
femur  upon  the  ilium,  the  curvature  forwards  of  the  lum- 
bar region,  and  the  convexity  which  the  anterior  wall  of 
the  abdomen  presents,  are  apt  to  be  among  the  first 
characteristic  features  of  the  disease,  which  attract  the 
attention  of  the  surgeon.     The  pubic  region  appears  to 

he  tilted  forwards  and  downwards,  while  the  lower  part 
of  the  trunk  appears  to  have  sunk  down  between  the 
upper  portion  of  the  thighs;  and  this  last  circumstance, 
which  actually  takes  place  on  account  of  the  ascent  of 
the  ossa  femorum,  gives  to  the  aims  the  semblance  of 
being  relatively  too  long,  the  extremities  of  the  fingers 
ranging  sometimes  nearly  on  a  level  with  the  upper  mar- 
gin of  the  patellae.     \'i<l>  Plates  i.  and  n. 


94  SYMPTOMATOLOGY. 

Both  of  the  great  trochanters  project  abnormally,  and 
are  seen  to  have  mounted  considerably  higher,  so  as  to  be 
situated  nearer  than  is  natural  to  the  crests  of  the  ilia, 
forming  with  the  retracted  muscles  which  surround  them, 
an  unusual  eminence,  somewhat  rounded  on  each  side,  at 
the  superior  and  lateral  part  of  the  hip,  while  the 
lower  and  posterior  portion  of  the  nates  is  generally  flat- 
ter than  in  the  healthy  condition  of  this  region.  The 
tuberosities  of  the  ischia,  carried  outwards  and  more  apart 
from  each  other,  are  denuded  of  muscular  tissue,  and 
covered  only  by  the  integuments. 

The  fold  in  the  groins  is  deeper,  its  direction  less  trans- 
verse and  more  vertical,  and  the  usual  niche  between  the 
buttocks  and  the  thighs  is  placed  higher,  and  more  curved 
outwardly  than  it  ordinarily  is. 

The  whole  of  the  inferior  extremities,  probably  owing 
to  want  of  exercise,  as  well  as  to  the  imperfect  develop- 
ment, which  takes  place  from  defective  nutrition,  and 
which  manifests  itself  in  the  muscular  and  osseous  tissues 
in  this  affection,  appear  more  slender  than  is  observed  in  a 
healthy  individual. 

The  thighs  sometimes  retain  their  normal  direction ;  at 
other  times  they  take  an  oblique  direction  from  above 
downwards  and  inwards,  forming  with  the  leg,  at  the 
femoro-tibial  junction,  an  angle  obtuse  outwardly,  while  the 
knee  presents  internally  an  unusually  acute  angular  aspect. 

Persons   affected  with  this  dislocation,  when  standing 


81  MPTOMATOLOGY.  95 

erect  in  a  passive  state,  can  always,  I  believe,  rest  upon 
t lie  entire  sole  of  the  foot.     In  this  posture  the  muscles 

around  the  hip  arc  more  relaxed  than  when  put  into  eon- 
traction,  during  the  various  exercises  of  progression  or 
locomotion,  and  the  femurs  are  thus  allowed  to  ascend  to 
their  ultimate  limit  upon  the  iliac  hones. 

As  a  consequence  of  this  ascent,  the  psoas  magnus  and 
iliacus  interims  muscles  of  either  side  are  put  upon  the 
stretch,  and  draw  forwards  the  lumbar  and  lower  dorsal  ver- 
tebrae, and  thus  in  the  most  marked  degree  can  be  seen  the 
unnatural  excurvation  of  the  loins  with  the  correspond- 
ing exaggerated  convexity  of  the  anterior  region  of  the 
abdominal  parietes.  Dupuytren  says,  "  Us  ne  touchent  le 
sol  que  par  la  pointe  des  pieds."  Observation,  however, 
goes  to  contradict  this  assertion  of  the  celebrated  French 
surgeon.  It  would  seem,  in  fact,  that  in  the  passive  erect 
attitude,  the  patient  can  rest  fully  upon  the  soles  of  both 
feet;  but,  while  the  heel  is  descending  to  the  ground,  the 
lumbar  region  becomes  still  more  incurvated,  owing  to  the 
increased  traction  then  exercised  on  both  sides  by  the 
tendons  of  the  psoas  magnus  and  the  iliacus  interuus. 

The  position  of  the  patient  remaining  the  same,  the 
toes  are  frequently  directed  straight  forward,  as  exhibited 
in  the  drawings,*  a  reference  to  which  will  aid  materially 
in  following  the  verbal  description  given.  Sometimes, 
however,  the   posture  of  the   individual   varying,  the   feet 

*    Vide  Plates  i.,  ii.,  and  iv. 


96  SYMPTOMATOLOGY. 

may  be  turned  outwards ;  or  inwards,  as  is  the  case  in 
the  corresponding  dislocation  of  traumatic  origin. 

One  of  the  most  characteristic  differential  signs  of  con- 
genital dislocation  of  the  head  of  the  femur  upon  the  dor- 
sum iiii,  is  the  disappearance,  as  soon  as  the  patient  is 
placed  horizontally  on  the  back,  of  most  of  the  symptoms 
observable  to  the  eye,  when  he  is  standing  in  the  erect  pos- 
ture. The  superincumbent  weight  of  the  trunk  is  then 
removed,  and  the  muscles  around  the  articulation  now  per- 
mit the  great  trochanters  to  descend  to  a  nearly  natural 
position ;  and  as  the  small  trochanters  also  approach  their 
normal  situation,  the  psoas  and  internal  iliac  muscles 
become  relaxed,  and  thus  the  curvature  of  the  loins,  and 
the  corresponding  convexity  of  the  abdomen  anteriorly, 
become  diminished  or  effaced. 

By  the  aid  of  manual  examination,  signs  are  disco- 
vered not  less  worthy  of  note  than  those  which  are 
observed  by  mere  inspection.  If  traction  upon  the  limb 
be  exercised,  so  as  to  act  from  above  downwards,  the 
limb  becomes  elongated,  the  head  of  the  femur  descends, 
the  great  trochanter  becomes  more  separated  from  the 
crest  of  the  ilium,  and  the  projection  they  previously 
formed,  is  found  to  have  diminished  ;  while  on  the  con- 
trary, if  force  in  an  opposite  direction  is  applied,  that  is, 
from  below  upwards,  the  head  of  the  femur  does  not  meet 
with  resistance  at  the  natural  locality  of  the  acetabulum,  but 
mounts  with  facility  to  its  abnormal  position  upon  the  dor- 


81  MPT0MAT0L0G1  .  97 

sum  ilii.  The  evidences  of  this  symptom  have  been  denied, 
and  thej  have  been  attributed  to  a  want,  of  proper  pre- 
cau(ii)ii  in  fixing  the  pelvis,  while  the  traction  w;is  made 
upon  one  side;  but  iii  those  cases  yhere  the  dislocation 
exists  on  both  sides,  both  limbs  can  be  made  to  descend 
at  the  same  time,  and  often  to  the  same  extent,  when 
they  are  both  simultaneously  pulled  upon.  The  only 
exception  to  this  symptom  occurring,  is  when  the  head  of 
the  lemur  has  escaped  from  the  natural  capsule  in  which 
it  was  originally  enclosed,  and  a  new  socket  has  been 
formed  upon  the  dorsum  of  the  ilium ;  after  the  man- 
ner of  those  new  formations,  which  occur  as  the 
result  of  traumatic  dislocations  in  this  region.  Under 
these  circumstances,  it  will  naturally  follow  that  the  head 
of  the  bone  will  be  more  or  less  confined  in  its  new  situa- 
tion, and  will  be  less  influenced  by  motion  imparted  to  it, 
than  when  it  simply  reposes  on  the  surface  of  the  ilium, 
unfettered  by  any  adventitious  osseous  effusion  in  the 
shape  of  a  new  receptacle  or  acetabulum..  ' 

When  the  head  of  the  femur  exists,  il*  a  motion  of 
flexion  be  given  to  the  thigh  upon  the  pelvis,  the  head  of 
this  bone,  instead  ot  turning  upon  its  axis,  will  describe 
an  are  of  a  circle,  the  centre  of  which  w  ill  seem  to  be 
at  the  union  of  the  neck  with  the  trochanter  major 
This  sign,  under  some  circumstances,  may  be  of  service, 
but  as  the  head  and  neck  of  the  lemur  are  often  stunted 
and  small,  and  sometimes  even  altogether  removed  during 


98  SYMPTOMATOLOGY. 

the  progress  of  the  displacement,  it  must  frequently  be 
inapplicable  and  deceptive. 

When  the  head  of  the  femur  is  in  its  natural  position, 
it  can  be  felt  by  exploring  the  fold  of  the  groin  during 
rotation  of  the  limb  outwards.  In  seeking  after  this  sign, 
the  hand  is  made  to  grasp  the  upper  and  outer  part  of  the 
thigh,  so  that  the  thumb  may  be  placed  transversely  in 
the  fold  of  the  groin,  a  little  external  to  the  point  where 
the  pulsation  of  the  femoral  artery  can  be  felt.  If  a 
movement  of  rotation  be  then  given  to  the  abdominal 
extremity,  the  head  of  the  femur,  if  it  be  in  its  natural 
place,  will  be  felt  rolling  under  the  thumb.  The  absence 
of  this  sensation  of  a  rounded  body  moving  under  the  fin- 
ger, as  M.  Pravaz  remarks,  is  a  certain  sign  of  displacement. 

In  obscure  cases,  as  may  occur  particularly  in  young 
subjects,  the  diagnosis  may  be  rendered  more  certain  by 
tracing  a  line — having  first  flexed  the  thigh  upon  the 
pelvis,  and  given  it  a  slight  adduction — from  the  anterior 
superior  spinous  process  of  the  ilium,  to  the  most  salient 
point  of  the  tuberosity  of  the  ischium.  This  line  will,  in 
the  normal  position  of  the  head  of  the  femur,  nearly  cor- 
respond with  the  summit  of  the  trochanter  major  ;  while 
if  the  head  be  dislocated  upwards  and  outwards,  it  will  pass 
over  the  central  part,  or  more  towards  the  base  of  this  pro- 
cess, according  to  the  extent  of  the  displacement.  Vide 
Plate  v. 

The   functional  derangements  of  the  joint  are  made 


31  HPTOMATOLOQ1  .  ■l-) 

manifesl  l»\  the  peculiarities  observable  duriDg  the  differ- 
ent acts  of  locomotion,  and  l>\  the  confined  or  exagg 
rated  movements  which  the  joint  can  be  made  to  perform. 
An  adult  person  laboring  under  the  effects  of  disloca- 
tion of  the  heads  of  both  femurs,  presents  peculiarities  in 
his  gait  during  the  diversified  efforts  of  using  the  inferior 
extremities,  which  are  not  to  be  met  with  in  any  variety  of 
lameness  resulting  from  the  other  maladies  occurring  at 
the  hip-joint.  In  walking,  owing  to  the  want  of  fixed- 
ness of  the  heads  of  the  femurs,  and  the  displacement 
which  they  must  undergo  of  alternate  depression  and  ele- 
vation, according  as  the  weight  of  the  body  is  transferred 
from  one  inferior  member  to  the  other,  and  also  owing  to 
the  strain  which  is  put  upon  the  psoas  and  the  internal 
iliac  muscles  upon  the  side  where,  for  the  moment,  the 
weight  of  the  trunk  is  thrown,  a  kind  of  double  lameness 
is  produced,  somewhat  resembling  the  hobbling  motion  of 
the  duck.  "  The  subjects  so  affected,  when  about  to 
commence  walking,  are  seen  to  elevate  themselves  upon 
the  point  of  the  feet,  to  incline  the  superior  part  of  the 
trunk  towards  the  member  which  is  about  to  support  the 
weight  of  the  body,  and  to  lift  the  other  with  an  effort, 
in  order  to  brine  it  forward  in  advance.  At  this  moment 
one  of  the  great  trochanters — that  which  corresponds  to 
the  column  of  sustentation — appears  to  become  approxi- 
mated to  the  crest  of  the  ilium  in  a  greater  degree  than 
while   standing  upon   both   feet.     From    this  mobility  in 


100  SYMPTOMATOLOGY. 

the  vertical  direction,  oscillations  of  the  trunk  take  place, 
which  render  the  walk  as  inconvenient  as  ungraceful. 
These  oscillations  are  often  accompanied  by  a  Crepitat- 
ing sound  loud  enough  to  be  heard  at  a  distance  of  seve- 
ral paces." 

Contrary  to  what  might  have  been  anticipated,  the 
effects,  resulting  from  the  abnormal  condition  of  the  heads 
of  the  femurs,  after  they  have  lost  their  natural  support  at 
the  cotyloid  cavity,  and  have  mounted  on  the  dorsa  of  the 
ilia,  are  less  observable  during  the  acts  of  running,  leap- 
ing, dancing,  &c,  than  during  simple  or  slow  progression. 
This  can  be  accounted  for,  by  the  energetic  contraction  of 
the  muscles  surrounding  the  hip-joints  retaining  the  heads  of 
the  femurs  in  a  more  fixed  position  during  these  quick 
movements,  and  by  the  rapid  transfer  of  the  weight  of  the 
trunk  from  one  extremity  to  the  other,  which  does  not 
allow  time  enough  for  the  heads  of  the  femurs — thus 
somewhat  solidly  held  by  the  muscles — to  pass  through 
their  accustomed  range  along  the  external  surface  of  the 
iliac  bones.  Protracted  locomotion,  however,  of  anv 
kind  is  not  borne  well  by  individuals  thus  affected.  The 
strain  upon  the  muscles,  consequent  upon  their  change  of 
direction  and  perverted  action,  the  friction  of  the  dis- 
placed heads  of  the  femurs  upon  the  ilia,  the  coustant 
efforts  kept  up  in  balancing  the  body  during  the  acts  of 
progression,  do  not  fail,  if  long  continued,  to  produce  the 
sensation  of  fatigue  and  pain. 

As  regards  the  isolated  movements,  which  cau  be  pro- 


SI  MP  rOM  ITOLOOY.  ]<il 

ed  .11  the  ilio-femoral  articulation  ilms  affected,  bj  im- 
parting motion  to  it  through  the  inferior  extremity, 
find  that  rotation  can  be  performed  without  much  impedi- 
ment Extension  and  adduction  are  executed  with  faci- 
lity; l>iit  the  limb  can  undergo  abduction  only  to  a  slight 
extent.  Flexion  can  be  produced  with  great  ease,  and 
some  instances  arc  related  where  the  limb  could  be  made 
to  touch  the  anterior  part  of  the  shoulder. 

It  should  be  recollected,  in  reference  to  the  diagnosis  of 
i his  displacement  of  the  hip-joint,  that  these  various  move- 
ments are  not  accompanied  by  pain,  when  moderation  and 
not  more  than  the  requisite  force  is  used  in  the  examina- 
tion of  the  functions  of  the  joint. 

The  extent  of  these  movements  may  be  somewhat 
modi  lied  by  the  effusion  of  osseous  matter  upon  the  sur- 
face of  the  ilium,  around  or  in  contiguity  with  the  head 
of  the  femur,  as  happens  in  those  cases  where  nature  has 
attempted  to  form  a  new  acetabulum. 

Congenital  Dislocation  of  the  Femub  dpok  the 
Ilium,  on  onl:  side  only. —  When  the  dislocation  <>1  the 
head  of  the  femur  upon  the  ilium  exists  but  on  one  Bide, 
the  general  characteristics  in  reference  to  the  affected  arti- 
culation, are  the  same  as  when  the  luxation  is  double. 

During  progression  there  is  some  deformity  oi  the  ver- 
tebral column*,  which,  on  account  of  the  shortness  ol  the 
displaced   extremity,  and   in   order  to  bring  the  centre  ol 


102  SYMPTOMATOLOGY. 

gravity  within  the  base  of  sustentation,  is  often  inclined 
laterally.  The  side  of  the  pelvis,  corresponding  to  the 
affected  articulation,  is  depressed. 

The  buttock  inferiorly  is  more  flat,  while  at  the  upper 
and  external  part  of  the  hip  there  is  seen  a  rounded  pro- 
tuberance corresponding  to  the  unnatural  portion  occupied 
by  the  trochanter  major. 

The  fold  between  the  nates  and  the  thigh  of  the  abnormal 
side  is  situated  higher,  and  is  directed  more  outwardly  than 
on  the  opposite  side. 

The  inguinal  fold  is  deeper  and  less  transverse,  and  in 
the  female,  the  border  of  the  vulva  corresponding  to  the 
luxated  femur  is  slightly  deflected,  being  carried  upwards 
and  outwards. 

The  trochanter  major,  now  much  more  prominent  than 
naturally,  is  seen  to  have  mounted  along  the  dorsum  ilii, 
and  to  have  approximated  the  crest  of  this  bone.  The 
limb  is  consequently  shortened  in  proportion  to  the  extent 
of  the  ascent  of  the  femur,  and  this  may  vary  from  a  few 
lines,  to  two  or  three  inches,  according  to  the  age  of  the 
patient  and  the  duration  of  the  displacement. 

The  affected  limb  has  the  appearance  of  having  suf- 
fered from  defective  nutrition,  not  being  as  large  as  the 
other ;  the  flesh  is  also  softer  than  that  of  the  limb  upon 
the  sound  side. 

In  cases  not  complicated  with  other  deformity,  the 
bones  of  the  thigh  and  leg,  measured  together,  offer  but 


SYMPTOMATOLOGY.  103 

little  difference  in  length,  in  either  extremity ;  but  in  ap- 
proaching  the  two  members,  the  two  anterior  and  supe- 
rior spinous  processes  of  the  ilia  being  placed  upon  a 
level,  the  malleolus  interims  of  the  affected  side  is  found 
to  be  situated  higher  than  upon  the  sound  side,  and  the 
extent  of  the  shortening  of  the  limb  will  be  greater  or 
less,  according  to  the  ascent  of  the  head  of  the  femur 
upon  the  ilium. 

The  thigh  is  more  oblique  from  above,  taking  a  direc- 
tion downwards  and  inwards,  with  a  tendency  to  cross 
the  limb  of  the  sound  side,  while  the  leg  inclines  in  an 
opposite  direction,  from  above  downwards  and  outwards, 
presenting  an  angle  more  or  less  obtuse  on  the  outer 
aspect  of  the  knee-joint. 

The  foot,  in  a  state  of  extension  to  counterbalance  the 
defect  resulting  from  the  unnatural  brevity  of  the  limb, 
generally  rests  upon  the  toes,  but  when  the  body  is 
inclined  forwards,  the  sole  of  the  foot  may  rest  entirely 
upon  the  ground,  the  toes  being  neither  remarkably 
inverted  nor  everted.  When  the  sole  of  the  foot  rests 
upon  the  ground,  and  the  weight  of  the  trunk  is  thrown 
upon  this  side,  the  lumbar  region  of  the  vertebral  column 
is  inclined  laterally  and  forwards. 

Manual  examination  discovers  the  same  characteristics 
appertaining  to  the  dislocation  on  one  side,  as  have  already 
been  noticed  as  accompanying  the  double  luxation.  If 
the  hand   is  applied   behind   the    trochanter    major,   and 


104  SYMPTOMATOLOGY. 

movements  of  flexion  and  extension  be  imparted  to  the 
thigh,  at  the  time  of  flexion,  the  head  of  the  femur  will 
be  felt  impressing  itself  upon  the  hand.  In  these  move- 
ments, the  head  of  the  femur  is  felt  describing  the  arc  of 
a  circle  from  above  downwards,  instead  of  pivoting  upon 
itself  as  it  does  when  situated  in  the  acetabulum. 

In  searching  by  pressure,  along  the  inguinal  fold  and  to 
the  outer  side  of  the  femoral  artery,  for  the  head  of  the 
femur  while  the  thigh  is  rotated,  instead  of  a  rounded 
body  rolling  under  the  fingers,  a  vacuity  is  felt  which  indi- 
cates the  absence  of  the  head  of  the  thigh  from  its  natu- 
ral  situation. 

If  the  patient  be  laid  on  the  back,  the  lateral  inflexion 
of  the  spine  becomes  less  marked,  or  disappears,  and  the 
limb  can  be  pushed  upwards,  so  that  the  upper  part  of  the 
femur  can  be  felt  within  a  short  distance  of  the  iliac  crest, 
or  it  can  be  pulled  downwards,  so  as  to  be  about  the  same 
length  as  the  sound  limb. 

After  flexing  the  thigh  upon  the  pelvis,  and  slightly 
adducting  it,  as  has  already  been  observed  when  speaking 
of  the  double  dislocation,  if  a  line  be  drawn  from  the 
anterior  superior  spinous  process  of  the  ilium  to  the  most 
prominent  part  of  the  tuberosity  of  the  ischium,  and  the 
summit  of  the  trochanter  major  is  found  to  surpass  supe- 
riorly this  line,  the  dislocation  of  the  head  of  the  femur, 
upwards,  may  be  supposed  with  great  certainty  to  have 
taken  place.     This  sign  is  useful  in  detecting  the  presence 


SYMPTOMATOLOGY.  '    L05 

of  the  single  congenital  dislocation,  the  diagnosis  of  which  is 
generally  more  difficult  than  in  the  double  form  of  tliis 
displacement 

While  in  the  erect  posture,  the  patient,  suffering  from 
single  congenital  luxation  of  the  femur,  is  apt  to  rest  the 
toes  of  the  affected  limb  upon  the  ground,  in  order  to 
compensate  for  its  defective  length.  When,  however,  the 
sole  is  entirely  placed  upon  the  ground,  the  sound  limb, 
being  then  the  longer,  becomes  flexed  at  the  knee,  and 
the  psoas  and  the  iliacus  muscles  in  this  position  of  the 
foot,  pulling  forwards  the  lumbar  vertebra?  towards  the 
affected  side,  twist  the  trunk,  which  is  also  thrown  back- 
wards, and  cause  the  region  of  the  loins  to  be  excur- 
vated,  and  the  abdomen  anteriorly  to  become  correspond- 
ingly convex  in  appearance. 

As  a  consequence  of  the  un fixedness  of  the  head  of 
the  femur,  and  the  tractions  exercised  by  the  psoas  mag- 
nus  and  iliacus  internus  muscles  of  the  affected  side,  the 
trunk  of  the  patient,  in  the  act  of  walking,  is  inclined 
at  first  towards  the  side  where  the  luxation  exists,  the 
flank  of  the  same  side  becomes  curved  forwards,  and  a 
movement  of  alternate  depression  and  elevation  of  the 
hip  takes  place,  producing  a  peculiar  postcro-lateral  lame- 
ness. 

When  the  patient,  resting  upon  the  displaced  mem- 
ber alone,  attempts  to  leap,  he  finds  it  almost  impossi- 
ble to  do  so  owing  to  the  absence  of  a  point  (Tappui  for 

8 


106     '  SYMPTOMATOLOGY. 

the  head  of  the  femur,  and  on  account  of  the  mutations 
which,  during  the  effort,  take  place  in  the  relative  position 
of  the  component  parts  of  the  ilio-femoral  articula- 
tion. 

The  different  movements  which  take  place  at  the 
abnormal  articulation,  in  regard  to  their  extent,  direction, 
and  freedom,  are  analogous  to  those  which  have  been 
noticed  while  considering  the  symptoms  of  the  double 
congenital  dislocation  of  the  hip-joint,  and  need  not  be 
again  repeated. 

In  connexion  with  this  account  of  the  symptoms  of 
congenital  dislocation  of  the  head  of  the  femur  upon  the 
ilium,  I  have  made  an  abstract  of  a  case  I  published  ori- 
ginally in  the  London  Lancet  in  1844,  in  which  the 
characteristics  of  this  affection,  as  presented  in  the  double 
form,  were  exceedingly  well  marked,  and  which  being  free 
from  the  complications  that  often  accompany  this  displace- 
ment, I  insert  here,  as  being  well  adapted  to  illustrate 
the  symptomatology  of  this  dislocation  in  the  adult. 

"  The  affection  of  which  I  propose  at  present  to  speak, 
I  consider  to  consist  in  a  transposition  of  the  head  of  the 
femur  from  the  cotyloid  cavity  upon  the  external  iliac 
fossa  of  the  os  innominatum,  occurring  during  intra- 
uterine existence,  generally  not  so  fully  manifested  in 
the  early  period  of  childhood  as  it  becomes  in  adult 
age,  when  some  of  the  symptoms  attendant  upon  it  are 
peculiar,  and  the  displacement  greater  and  more  marked 


SI  MPTOMATOLOGY.  J07 

than  in  the  usual  luxation  of  this  character  resulting  from 
external  injury. 

"  Some  weeks  ago,  a  ease  came  under  niv  observation 
of  a  lad,  who,  from  the  curious  and  hobbling  motion  of 
his  gait,  and  other  symptoms,  I  judged  to  be  laboring 
under  that  peculiar  affection,  which  has  been  termed  con- 
genital dislocation  of  the  head  of  the  femur  upon  the 
dorsum  of  the  ilium.  With  a  view  of  ascertaining  the 
nature  of  the  affection,  and  of  determining  the  diagnosis, 
I  requested  my  friend  Mr.  Clark,  of  the  British  Navy,  to 
see  this  case  with  me,  and  as  upon  examination,  every 
appearance  and  account  given,  went  to  show  that  the 
displacement  was  owing  to  an  unusual  luxation  of  the 
heads  of  both  femurs  upon  the  iliac  bones,  I  have  deemed 
the  case  worthy  of  attention,  and  have  drawn  up  the  fol- 
lowing statement  of  it,  to  which,  as  illustrative  of  the 
position  of  the  parts  presented  externally,  the  annexed 
drawings  are  added.      Vide  Plates  i.,  il,  and  iv. 

"  Benjamin  Gott,  the  subject  of  this  article,  is  now 
nineteen  years  of  age,  a  shoemaker  by  trade,  of  good 
temperament,  and  has  always  been  in  the  enjoyment  of 
perfect  health,  with  the  exception  of  slight  indisposition 
at  times.  From  his  earliest  recollection,  as  well  as  that 
of  the  persons  who  brought  him  up,  he  has  labored  under 
an  impediment  in  his  walking,  but  has  never  met  with 
an\  accident  which  confined  him  to  his  bed,  or  to  which 
his   present  condition    could    be  attributed.      There  is  no 


108  SYMPTOMATOLOGY. 

abscess  nor  fistula  around  either  hip-joint,  nor  is  there  any 
mark  or  cicatrix  to  be  seen  in  the  ilio-femoral  region  to 
induce  the  belief  that  those  conditions  which  frequently 
attend  or  accompany  the  spontaneous  luxation  from  mor- 
bus coxarius  have  ever  existed. 

"  When  looked  at  while  he  is  standing  in  the  erect 
position,  a  striking  want  of  proportion  and  harmony 
between  the  upper  and  lower  portions  of  the  body  is  at 
once  observed,  the  lower  appearing  relatively  shorter  than 
the  upper,  and  the  hands, — owing  to  the  ascent  of  the 
heads  of  both  femurs  upon  the  iliac  bones  considerably 
above  the  usual  situation  of  the  cotyloid  cavities,  and  the 
consequent  falling  down  or  sinking  of  the  pelvis, — are  seen 
to  descend  about  five  inches  below  their  usual  point,  the 
ends  of  the  fingers  reaching  beyond  the  superior  margin 
of  the  patellae,  when  the  arms  rest  along  the  sides  of  the 
body.*  The  head,  neck,  trunk,  and  superior  extremities 
are  well  developed,  but  the  trunk  appears  to  be  somewhat 
thrown  forwards,  and  the  lower  or  abdominal  portion  pre- 
sents a  remarkable  and  salient  projection,  while  in  the 
lumbar  region  there  is  a  corresponding  hollow  or  depres- 
sion. The  inferior  extremities,  which  do  not  deviate 
much  from  the  normal  position,  as  regards  the  direction 
of  the  knees  or  toes,  appear  shorter,  and  are  more  attenu- 
ated than  natural,  and  towards  the  junction  of  the  pelvic 
extremities  with  the  trunk,  the  thigh  bones  seem  to  be 

*   Vide  Plates  I.  and  n. 


SYMPTOMATOLOGY.  ] 09 

separated  from  each  other  farther  than  natural,  so  that, 
superiorly,  a  space  between  them  is  left,  giving  to  the 
perineal  region  a  resemblance  in  breadth  to  that  of  the 
female.  With  respect  to  the  position  of  the  knees  and 
toes,  this  part  of  my  description  differs  from  that  given  by 
I)iipu\  i n ■  1 1 .  who  states  that  the  toes  were  inverted  in 
some  of  his  patients,  and  that  there  was  also  a  disposi- 
tion of  the  knees  to  approximate.  It  is  probable  that 
this  lias  been  more  or  less  the  condition  of  things  in  the 
present  instance,  as  the  lad  states  that  his  foot  had  for- 
merly an  inward  tendency,  and  that  his  limbs,  within  the 
last  few  years,  have  assumed  a  more  natural  direction. 
As  regards  the  position  of  the  sole  of  the  foot,  there  is  also  a 
difference  to  be  observed  in  this  case,  for  in  the  erect  posi- 
tion the  sole  rests  entirely  upon  the  ground,  as  will  be  seen 
by  a  reference  to  the  drawings,  nor  is  there  any  elevation  of 
the  heel,  which  forms  a  symptom  of  this  kind  of  disloca- 
tion w  hen  it  is  the  result  of  external  injury.  In  tracing 
the  femur  of  one  side  (both  being  similarly  situated) 
downwards  from  its  present  resting-place,  the  upper  mar- 
gin of  the  great  trochanter  is  felt  to  be  nearly  on  a  level 
with  the  crest  of  the  ilium,  and  the  shaft  to  incline  slightly 
downwards  and  forwards  to  the  femoro-tibial  articulation, 
-w  hich,  in  every  respect,  is  natural.  The  pelvis,  instead 
of  having  the  usual  oblique  position,  approaches  more  to 
the  vertical  direction  ;  the  sacro-vertebral  angle,  and  upper 
portion  of  the  sacrum  inclining  downwards  and  forwards, 


110  SYMPTOMATOLOGY. 

while  the   coccyx  and  lower  pieces  of   the  sacrum  are 
forced  upwards  and  backwards.     By  tracing  the  superior 
margins  of  the  ossa  ilia  from  the  posterior  superior  spinous 
processes  forwards,  to  the  anterior  superior  spinous  pro- 
cesses of  these  bones,  the  ossa  innominata  are  found  to 
be  tilted  much  more  forwards,  than  is  observed  in  the  nor- 
mal inclination  of  the   pelvis,  and  the  anterior   superior 
spinous  processes  are  depressed  downwards   and   forwards 
so  far,  that  the  convexity  of  the  iliac  crests  presents  almost 
an  anterior    aspect.      The  symphysis    and  arch   of  the 
pubes  are  thus  thrown  downwards,  whilst  the  tuberosities 
of  the  ischia  are  made  to   ascend  slightly  upwards  and 
backwards,  so  that  these  eminences  are  nearly  on   a  level 
with  the   arch  of  the  pubes,  and  the  rami  of  the  ischia 
and  of  the  ossa   pubis    consequently   almost  horizontal. 
Although  the  position  of  the  pelvis  is  thus  out  of  its  usual 
inclination,  there  is  not  apparent  any  relative  alteration  of 
the  individual  parts  which  compose  this  important  part  of 
the  skeleton.     Thus,  the  alee  of  the  iliac  bones  are  not 
misshapen,  and  the  tuberosities  of  the  ischia  are  distant  from 
each  other  about  four  inches,  while  at  the  anterior  superior 
spines  of  the  ilia  there  is  a  space  of  nine  inches  and  a 
quarter.      Between  the  anterior  superior  iliac  spine  and 
the  tuberosity  of  the  pubes  the  measurement  is  five  inches 
md  three-quarters,  which  is    slightly  more  than    in  the 
generality  of  young  adult  males,  and  the  pelvis  so  far  gene- 
rally  well  formed,  as  regards  its    relative  dimensions,   is 


31  tfPTOM  LTOLOGY.  1  1  1 

also  apparently  free  from  an\  of  the  results  of  rachitis,  or 
any  of  the  oilier  forms  of  disease  to  which  the  osseous 
tissue  is  liable* 

"The  mosl   prominenl  deviatioD  from  the  nor;. 
of  pans,  which    the    deformity  in  question    presents,  is 
caused  by  the  unnatural  position  and  remarkable  proj 
don  of  the  great  trochanters.     The  heads  of  the  fem 
having  escaped  from   the  acetabala,  have   mounted   upon 
the  dorsa  of  the  ilia  so  high  as  to  earn  the  upper  porti 
of  the  trochanters  nearly  on  a  level  with  the  iliae  cri 
The  heads  of  the  femurs   being   thus  so  far  removed  from 
the  proper   situation   of  the   cotyloid   cavities,  the   nearly 
equilateral   triangle  which   the   anterior  superior   spine  of 
the  ilium,  the  tuberosity  of  the  pubes,  and  the  trochanter 
major,  will  form,   when   the   coxo-femoral   articulation  is 
undisturbed,  is  entii  ken   up,  and  a  prominenc 

produced    by  the  projecting   trochanters  on    either  side 

*  ]  liiirkcJ  that  this  subject  was  young,  and  that  the  cha 

dissection  |  place  in  the  osseous  tissues  at   a  m  f  the 

lisease,  had,  as  yet,  in  aim  bee  >me  but  slightly  apparent  outwardly. 

Although  in  the  case  abo\  d,  as  far  as  could   be  ascertained  bj  i 

t,  the  diameters  of  the  pelvis  remained  nearly  nat 
am  perfi  ctly  ^:> ' i~ti.-c I  t'r<  m  dissections  I  I  f  several  cases  "t'  this  1   i 

tli.-  diameters  of  the  pelvis,  both  at  ti>  inferior  stra 

illy  altered. 

Tl  from  the  asc  trtaiiu  ■  ! 

affectii  d  occurring  more  frequently  in   females  than  in  male-  ;  and 
accoucheur  tin-  necessity  "t  being  fully  prepared  t"  encounter  much  difficulty  during 
parturition,  where  tin-  luxati  i  tin-  female,  whether  il  ho  single  "r  dou 


112  SYMPTOMATOLOGY. 

marked,  that  even  a  casual  observer  could  riot  fail  to  notice 
it.  In  the  present  case  of  congenital  luxation,  the  heads 
of  the  femurs  rest  also  higher  up,  and  more  posteriorly, 
than  in  the  common  dislocation  from  external  injury,  and 
the  normal  relative  position  of  the  head  and  trochanter, 
with  the  surface  of  the  iliac  bone,  is  maintained,  that  is, 
the  head  of  the  femur  is  not  thrown  backwards  and  the 
trochanter  forwards,  as  generally  takes  place  in  this  form 
of  the  traumatic  luxation.  The  head  and  neck  of  the 
bone  standing  out,  as  it  were,  nearly  at  a  right  angle  from 
the  resting-place  on  the  dorsum  of  the  ilium,  gives  the 
trochanters  the  prominent  appearance  which  they  present, 
and  this  also  will  enable  us  to  account  for  the  non-inversion 
of  the  toes,  and  the  almost  natural  direction  of  the 
limbs. 

"  Besides  the  other  symptoms,  such  as  shortening  of 
the  limbs,  the  slipping  up  of  the  head  of  the  bone  on  the 
external  iliac  fossa,  and  the  unnatural  relation  of  the  great 
trochanter,  which  this  luxation  presents  in  common  with 
the  other  dislocations  in  which  the  head  of  the  femur  is 
carried  upwards  and  outwards,  in  a  similar  direction,  the 
muscles  in  connexion  with  the  joint  offer  some  peculiari- 
ties worthy  of  remark.  The  spinal  muscles,  which  form 
the  sacro-spinal  mass,  taking  their  origin  from  the  sacrum, 
umbar  vertebrae,  and  posterior  part  of  the  ossa  ilia,  and 
running  along  the  vertebral  grooves  on  each  side  of  the 
spinous  processes   of  the  vertebrae,  are  found  to  be  hard, 


SYMPTOMATOLOGY.  113 

Cense,  and  prominent,  particularly  in  the  lumbar  region  ;  the 
psoas,  and  the  internal  iliac  muscles, — coming  from  tin-  low  er 
dorsal  and  lumbar  vertebrae  and  the  internal  iliac  fossae,  to 

be  inserted  into  the  small  trochanters, — being  pulled  upon 
l>\  the  ascent  of  the  femur  and  stretched  over  the  brim  of  the 
pelvis  now  acting  like  a  pulley,  are  also  found  tense  and 
cord-like,  while  nearly  all  the  muscles  of  the  superior 
part  of  the  iliac  region,  the  gluteus  maximus,  medius,  and 
minimus,  &c,  are  retracted  towards  the  crest  of  the  iliac 
bones, — 'oil  ils  forment,  autour  de  la  tete  du  femur  une 
espece  de  cone,  dont  la  base  est  a  l'os  iliaque  et  le  som- 
met  au  grand  trochanter.' — (Dupuytren.) 

"  The  particulars,  so  far  stated,  refer  to  the  subject  in 
the  standing  attitude  ;  but  in  the  recumbent  position,  some 
of  the  causes  of  displacement,  such  as  the  physiological 
action  of  the  muscles  and  the  weight  of  the  superior 
parts  of  the  body  ceasing  to  exist,  the  signs  of  this  affec- 
tion become  evidently  less  marked,  and  in  some  respects 
almost  effaced,  which  never  is  the  case  in  the  usual  trau- 
matic dislocation.  The  muscles,  now,  not  being  called 
into  action,  the  hollow  in  the  lumbar  region  disappears, 
the  abdomen  does  not  present  the  anomalous  projection 
formerly  alluded  to,  the  pelvis  seems  to  acquire  a  more 
natural  inclination,  the  head  and  trochanter  descend  seve- 
ral inches  more  towards  the  usual  situation  of  the  coty- 
loid cavity,  and  present  an  elevation  neither  so  prominent, 
nor  so   much   removed    from    the   normal    position   thej 


114  SYMPTOMATOLOGY. 

ought  to  occupy.  The  measurement  from  the  tubero- 
sity of  the  pubes  to  the  summit  of  the  great  trochanter  is 
seven  inches  and  a  quarter,  when  in  the  recumbent  pos- 
ture ;  while  it  is  nine  inches  and  a  half  when  he  is  stand- 
ing. 

"  In  walking,  the  heads  of  both  femurs  ascending  and 
descending  alternately,  upon  the  dorsa  of  the  iliac  bones, 
and  playing,  as  it  were,  through  a  space  of  nearly  three 
inches,  produce  the  hobbling  motion  which  has  been 
mentioned.  Thus,  while  the  body  is  supported  upon  the 
right  limb  in  the  act  of  stepping,  the  right  femur  ascends ; 
while  the  left,  being  freed  from  the  superincumbent 
weight  of  the  trunk  and  superior  extremities,  descends,  to 
ascend  again  as  soon  as  the  left  foot  rests  upon  the 
ground,  and  the  weight  of  the  body  is  transferred  to  it. 
Contrary  to  what,  at  first,  might  be  anticipated,  this 
unsteady  gait  is  less  observable  in  the  act  of  running 
than  in  walking,  the  increased  energy  of  the  muscular 
contraction,  and  the  more  rapid  movements  of  the  limbs 
not  permitting,  nor  allowing  time  for,  the  head  of  the  bone 
to  pass  through  its  accustomed  range  of  motion,  during 
the  slower  mode  of  progression.  Although,  as  has  just 
now  been  said,  the  alternating  movements  of  the  body  are 
not  so  marked  in  the  quicker  motion  of  running  as  in 
walking,  yet  owing  to  the  friction,  more  or  less,  of  the  dis- 
placed head  of  the  femur  upon  the  external  iliac  fossae,  the 
altered  and  unfavorable  position  in  which    the    muscles 


SYMPTOMATOLOGY.  1  I  5 

have  now  to  act,  and  the  irregular  and  fatiguing  swinging 
of  the  body  from  one  side  to  the  other,  this  individual  is 
unable  to  take  exercise  in  the  ereci  posture,  without.  s<  on 
evincing  signs  of  discomfort,  and  complaining  of  consi- 
derable pain,  more  particularly  in  the  groins  and  lumbar 
regions. 

"  By  grasping  the  thigh,  and  moving  the  limb  after  the 
pelvis  is  fixed,  a  sensation  of  crepitus,  resembling  that 
given  by  joints  which  have  suffered  from  rheumatic  inflam- 
mation, or  effusion  into  their  cavities,  is  distinctly  per- 
ceived. From  the  present  abnormal  position  of  the  [tarts 
around,  and  in  connexion  with  the  ilio-femoral  articula- 
tion, as  a  natural  consequence,  the  various  motions  of  the 
inferior  extremities  are  considerably  interfered  with,  and 
limited,  but  by  no  means  are  they  so  restricted  as  in  the 
traumatic  form  of  this  dislocation.  Adduction  of  the 
extremity  is  not  much  interfered  with,  and  one  thigh  can 
be  carried  over  the  other  with  facility,  but  abduction  is 
performed  with  difficulty,  the  thigh  having  but  a  few 
inches  of  latitude  in  this  direction  ;  and  in  the  endeavor  to 
sit,  as  in  the  attitude  of  riding  on  horseback,  across  a  high 
chair  of  the  common  breadth  in  the  seal,  it  is  found  that 
this  position  cannot  be  effected,  owing  to  the  limited 
extent  of  separation  allowed  to  the  ossa  lemorum.      While 

thf  knee-joint  is  not  bent,  the  movements  anteriorly  are  con- 

siderabl)   impeded,  but  when    the  thigh  is   Hexed  upon  the 


116  SYMPTOMATOLOGY. 

pelvis,  as  takes  place  in  the  act  of  stepping  upon  a  foot- 
stool, or  going  up  a  stair-case,  little  effort  is  required. 
The  motion  of  the  thigh  directly  backwards  is  somewhat 
confined,  but  rotation  inwards,  and  particularly  outwards, 
is  nearly  natural. 

"  In  the  sitting  posture,  while  the  trunk  is  kept  nearly 
erect,  the  lumbar  vertebrae  are  not  then  dragged  so  much 
forward,  and  this  appears  to  be  the  position  least  irksome 
while  it  can  be  maintained  ;  but  in  the  stooping  attitude, 
as  that  of  the  cobbler  at  work,  which  in  his  trade  this 
youth  has  to  adopt,  the  lumbar  and  lower  dorsal  vertebrae 
assume  a  convexity  backwards,  and  the  psoae  being  thus 
put  upon  the  stretch,  great  uneasiness  is  experienced  in 
the  loins  if  this  posture  be  prolonged  for  any  considerable 
length  of  time. 

"  These,  then,  are  some  of  the  most  marked  pathogno- 
monic characters  observed  in  this  congenital  affection, 
which,  I  am  inclined  to  believe,  is  of  much  more  common 
occurrence  than  the  slight  notice,  or  rather  entire  silence 
observed  regarding  it  by  authors  in  Great  Britain,  or  my  own 
country,  would  induce  me  to  suppose.  Thus  we  are  told 
by  Dupuytren  that  he  met  with  twenty-five  cases  of  the 
"  luxation  originelle  de  la  tete  du  femur."  Jules  Guerin 
records  that  he  has  seen  over  thirty  cases,  and  within  the 
last  two  years,  since  my  attention  has  been  attracted  to 
the  subject,  although  I  have  been  prevented  by  circum- 
stances from  making  as  many  observations  on  this  subject 


st  MPTOH  kTOLOGY.  1  17 

as  I  might  otherwise  have  done,  I    have  met  with  four 
well-marked  cases.* 

•  From  a  consideration  of  the  serious  evils  which  a 
continuation  of  this  displacement  will  entail  upon  the 
sufferers,  as  regards  the  enjoyments  of  life,  and  the 
performance  of  its  duties,  it  behoves  the  surgeon  to 
he  prepared  to  form  a  correct  diagnosis  in  relation 
to  this  affection,  to  prevent  erroneous  and  painful  prac- 
tice being  resorted  to,  and  in  order  that  the  proper 
therapeutic  means,  as  far  as  jet  known,  or  superior  judg- 
ment might  suggest,  may  be  adopted  to  remedy  the 
deformity  before  the  approach  of  adult  age  would  pro- 
scribe the  utility  of  such  an  attempt.  The  subject  of  the 
case  I  have  detailed  has  been  sent  down  to  Margate  by 
his  medical  attendants,  for  six  months  at  a  time,  for  the 
benefit  of  his  hip-joints,  under  the  supposition  of  the 
affection  being  of  a  scrofulous  nature;  and  we  find  Du- 
puvtren  writing  as  follows  in  regard  to  this  point:  '  Plu- 
sieurs  individus,  affectes  de  luxation  originelle,  ont  ete 
contraint,  par  suite  de  cette  erreur  de  diagnostique,  a  gar- 
der  le  lit  pendant  plusieurs  annces.  J'en  ai  vu  d'autres, 
qu'on  avait  forces  a.  supporter  des  applications,  sans  noni- 

*  Since  this  paper  was  written,  I  have  seen,  at  Paris,  London,  and  New  York, 
at  least  twenty  more  cases  of  this  dislocation,  which  have  .'■till  farther  confirmed  the 
opinions  I  have  advanced  in  relation  t<>  its  greater  frequency  than  is  generally  sup- 
posed. From  these  additional  observations  which  I  have  had  an  opportunity  of  mat- 
ing, I  am  also  inclined  to  corroborate  the  opinion  of  Dupuytren  regarding  its  more 
common  occurrence  in  the  female 


118  SYMPTOMATOLOGY. 

bre,  de  sangsues,  de  vesicatoires,  de  cauteres,  et,  surtout, 
de  moxas.  Je  me  rappelle,  entre  autres,  line  jeune  fille 
qui  souffrit  l'application  de  vingt-et-un  moxas  autour  des 
hanches,  sans  que  ce  traitement,  inutile  ou  barbare,  cut 
apporte  aucun  changement  a  la  situation  de  cette  infor- 
tunee.' 

"  The  affections  most  likely  to  be  confounded  with  or 
mistaken  for,  the  congenital  luxation  of  the  head  of  the 
femur  upwards  and  outwards  upon  the  dorsum  of  the 
ilium,  are  the  dislocation  which  takes  place  in  the  same 
direction  at  the  ilio-femoral  articulation,  as  the  result  of 
external  injury  ;  or  that  inflammation  of  the  hip-joint  whe- 
ther accompanied,  or  not,  by  the  spontaneous  luxation,  as  it 
is  called,  of  the  femur  upon  the  external  iliac  fossa,  which 
results  sometimes,  as  a  consequence  of  the  absorption  and 
destruction  of  the  head  and  neck  of  the  bone,  during  the 
progress  of  that  strumous  disease  of  the  hip-joint,  known 
generally  by  the  name  of  morbus  coxarius.  Upon  exami- 
nation, however,  each  of  these  affections  will  be  found  to 
possess  characteristics  sufficiently  remarkable  to  enable  us 
to  arrive,  with  reasonable  certainty,  at  the  differential  diag- 
nosis. In  the  recent  dislocation  from  external  injury 
upon  the  dorsum  ilii,  the  shortening  of  the  limb,  the 
inversion  of  the  toes,  the  lessened  mobility  of  the  joint, 
and  more  flattened  appearance  of  the  affected  hip,  are  not 
difficult  of  detection.  The  strumous  diathesis  of  the 
patient,  and  the  relation  of  his  case  by  himself  or  friends, 


s1*  MPTOM  OTOLOGY.  I  i  9 

the  previous  inflammatory  condition  of  the  hip-joint,  with 
the  accompanying  symptoms  of  fever,  pain,  &c,  the 
formation  of  abscess,  the  existence  of  fistula?,  and  in  the 
latter  stage  the  ulceration  and  disappearance  of  the  head 
and  neck  of  the  bone,  the  trochanter  alone  being  left  re  ti 
in  the  acetabulum,  or  upon  the  dorsum  of  the  ilium,  the  fiv- 
quent  resulting  anchylosis  and  flat  aspect  of  the  hip,  are 
symptoms  sufficiently  pathognomonic  to  characterize  the 
condition  of  things  usually  attendant  upon  the  various  phases 
of  hip-disease  While,  in  regard  to  the  congenital  trans- 
position of  the  head  of  the  femur  upon  the  external  iliac 
fossa,  the  whole  history  of  the  patient,  from  the  earliest 
period  of  infancy  up  to  the  time  that  relief  or  advice  is 
applied  for,  the  lameness  shown  upon  the  first  attempts 
to  walk,  the  general  good  health  he  has  enjoyed,  the  total 
absence  of  primary  inflammatory  symptoms,  the  immunity 
from  antecedent  injury,  the  extraordinary  hobbling (clo- 
chant)  gait  during  the  act  of  slow  progression,  the  prominent 
aspect  of  the  abdomen,  and  the  corresponding  hollow 
appearance  of  the  lumbar  region,  the  existence  general!}  of  a 
double  ami  similar  luxation  on  both  sides,  the  partial  or  total 
disappearance  of  many  of  the  above  symptoms  in  the  recum- 
bent position,  the  unusual  projection  of  the  great  tro- 
chanter, owing  to  the  presence  and  direction  of  the  head 
and  neck  of  the  femur,  which  are  placed  nea.lv  at  a  right 
angle  and  not  in  a  line  with  the  surface  of  tin  iliac 
bone,  as   happens   in   the    traumatic   luxation;   ami   ab 


120  SYMPTOMATOLOGY. 

all,  the  ascent  and  descent  of  the  head  of  the  femur  upon 
the  external  iliac  fossa,  through  a  space  of  nearly  three 
inches,  the  upper  margin  of  the  trochanter  major  becom- 
ing nearly  horizontal  with  the  crest  of  the  ilium,  or 
appearing  several  inches  below  the  same  point,  and 
according  as  the  limb  is  pushed  upwards  or  pulled  down- 
wards ; — these  data,  taken  collectively,  and  in  connexion 
with  the  entire  freedom  from  all  pain  during  the  attempts 
to  move  the  parts  about  the  seat  of  the  displacement,  will 
form  an  assemblage  of  peculiarities  so  evidently  and  pal- 
pably different  from  the  circumstances  accompanying 
either  of  the  two  forms  of  lesion  already  referred  to,  that 
we  are  obliged  to  look  upon  the  morbid  condition  asso- 
ciated with  the  group  of  symptoms  last  enumerated  as 
belonging  to  another  species  of  disease,  and  to  classify  it 
as  more  properly  belonging  to  that  genus  of  affections 
which,  in  more  modern  times,  have  received  the  name  of 
congenital  luxations. 

"  It  would  appear  that  the  congenital  luxation  of  the 
head  of  the  femur  is  more  or  less  of  a  hereditary  charac- 
ter, and  that  females  are  more  subject  to  it  than  males. 
I  have  not  had  the  means  of  confirming  the  former  obser- 
vation, but  should  be  inclined  to  give  credence  to  it,  as 
experience  has  corroborated  the  existence  of  this  family 
predisposition  in  Talipes,  which  affection  most  proba- 
bly belongs  to  the  same  class  of  maladies  as  the 
congenital    dislocation  of  which  we  have   been    speak- 


SYMI'TOMATOUM^  .  I  J  I 

ing.  In  relation  to  its  more  frequent  occurrence  among 
females,  Dupuytren  states;  that  out  of  the  twenty-five 
cases  which  he  had  seen,  three  onlj  wen-  males;  of  the 
cases  which  have  come  under  mj  own  observation,  the 
greater  proportion  w  ere  females. 

"  The  peculiarities  and  symptoms  accompanying  con- 
genital luxation  of  the  head  of  the  femur  upon  the  dor- 
sum ilii,  being  found,  upon  comparison,  to  be  so  different 
from  either  of  the  other  forms  of  the  disease  above  alluded 
to,  and  with  which,  from  a  cursory  examination,  it  might 
be  confounded,  we  are  naturally  led  from  seeing  a  result 
or  effect  so  different,  to  seek  also  for  a  difference  of  ante- 
cedence or  cause.  The  celebrated  surgeon,  to  whom  we 
have  last  alluded,  asks,  in  relation  to  the  cause  of  displace- 
ment, '  Can  it  be  the  product  of  a  disease  occurring  to 
the  foetus  in  the  womb  of  the  mother,  and  cured  before 
birth  !  Can  it  be  the  result  of  an  effort,  or  of  violence, 
which  might  have  caused  the  head  of  the  femur  to  escape 
from  the  cotyloid  cavitj  ;  and  the  cavity  itself,  might  it 
not  become  obliterated  without  disease,  and  oiil\  because 
from  want  of  action,  it  would  become  useless  1  Can 
nature  have  forgotten  to  mould  a  cavity  for  the  head 
of  the  lemurs, — or  rather,  can  this  cavity,  which  iv  the 
result  of  the  concurrence  and  union  oi  the  three  pieces 
of  which  the  os  inuominaium  is  composed,  have  remained 
imperfect  on  account  of  some  obstacle  to  the  evolution  of 
the  bone,  as   M.  Breschet   has  been  induced  to  suppose  V 

9 


122  SYMPTOMATOLOGY. 

Each    of    the  causes    named    in    the    foregoing;   interro- 
gatories might,  we  can   conceive,  be   supported  by  argu- 
ments more  or  less   favorable,  none  of   them,   however, 
bearing  a  character  so  entirely  conclusive  as  to  carry  impli- 
cit conviction,   or   sufficiently   satisfactory   to   render  far- 
ther  investigation    into    the    origin    of    these    affections 
unnecessary.       If    disposed     to     attribute     this     transpo- 
sition  of  the  head  of  the  bone   to  some  violence    exerted 
during  the  act  of  parturition,  it  would  be  difficult  to  ima- 
gine, even  when  we  consider  the  different  positions  which 
the  foetus  may  assume  in  the  uterus,  by  what  means  the 
mechanical  force  could  be  applied  so  as  to  displace  the  head 
of  the  bone  in  an  upward  direction,  or  by  what  species  of 
manipulation,    either  instrumental   or   manual,  the  accou- 
cheur could   so  proceed,  as  to  produce  the  transfer  of  the 
head  of  the  femur  upwards  and  outwards   upon  the  dor- 
sum  ilii,  in    other  words,  in   a   direction  exactly  contrary 
to  that  of  the  force  which  may  be  supposed  to  be  brought 
into  play.     Nor  would  it  be  more  easy  to  follow  the  head 
of  the  bone,  after  it  had  been  once  dislocated  downwards 
into  the  foramen  ovale  by    traction, — as   some    have  sup- 
posed, during   a    difficult   labor  with   a  breech  or   lootling 
presentation, — taking    again  an  upward   course   over   the 
natural  position   it  ought   to   occupy   at  the  acetabulum, 
and    refusing   to  remain   quiescent   until   it  had  arrived  at 
the  external  iliac  fossa.     Something   may  be  said  in  sap- 
port  of  the  theory  of  the  arret  de  developpement,  as  con- 


B1  MP TOM kTOLOGl  .  I  23 

tributiog  to  the  primary  displacement  of  the  articulating 
surfaces,  bat,  in  the  present  case,  if  we  can  judge  from 
the  projecting  trochanters,  there  is  but  little  alteration  as 
regards  the  head  and  neck  of  the  fetuur,  and  autopsic 
examinations  which  have  been  made,  go  to  prove  the  fill- 
ing np  and  contraction  of  the  acetabulum  from  its  inutility 
and  consequent  inactivity,  rather  than  any  imperfection 
in  the  ossification  of  the  cotyloid  cavity  at  the  junction 
of  tlic  three  pieces  which  unite  to  form  it,  and  which 
should  I)'-  the  place  where  the  occurrence  of  auy  defect, 
if  any  existed  in  the  evolution  of  the  osseous  tissue, 
would  be  observable,  according  to  M.  Breschet's  theory. 
The  hypothesis  of  M.  Dupuytren,  that  a  primary  imperfec- 
tion of  the  germ  ('des  vices  de  conformation  originels,  et  qui 
tiennent  a  un  defaut  dans  {'organization  des  germes')  must 
have  some  relation  with  the  cause  of  the  displacement — and 
which  idea  led  him  to  gn  e  the  name  of  original  luxations  to 
this  class  ol  affections — carries  but  little  probability  with 
it;  nor  does  the  position  of  the  thighs,  Hexed  as  they  are 
upon  the  abdomen  of  the  child  in  utero,  and  the  conse- 
quent pressure  of  the  head  of  the  femur  against  the  lower 
and  interior  portion  of  the  iho-femoral  capsule,  satisfac- 
torily explain  the  reason  of  the  ascent  of  the  head  o\  the 
boue  upon  the  ilium.  We  can  imagine  that  this  position 
ol  the  head  ol  the  femur,  and  the  ualuralU   shallow  state  of 

the   acetabulum  during  foetal  life,  niaj    predispose  to  the 
displacement;  but  we   do  not  believe  that   mere  position 


124  SYMPTOMATOLOGY. 

without  the  action  of  some  morbid  auxiliary  cause,  could 
alone  have  the  effect  of  bringing  about  the  pathological  con- 
dition of  which  we  are  treating.  Although  it  is  well  known 
that  the  child,  while  jet  in  the  womb,  is  liable  to  many  dis- 
eases, yet  children  who  have  been  born  with  this  altered  re- 
lation of  parts  at  the  ilio-coxal  articulation  have  not  shown 
any  particular  bad  condition  of  health  at  birth,  sufficient  to 
attract  the  attention  even  of  medical  attendants,  and  this 
consideration  and  the  absence  of  anything  like  inflamma- 
tory engorgement,  abscess,  fistula,  or  cicatrix,  at  the 
period  of  birth,  must  leave  little  doubt  that  the  displace- 
ment cannot  have  for  its  origin  that  strumous  affection 
which,  in  extra-uterine  life,  we  sometimes  remark  to 
be  the  cause  of  spontaneous  luxation  of  the  head  of 
the  femur  upon   the  dorsum  of  the  ilium. 

"  The  remote  cause  then,  of  the  class  of  congenital 
deformities,  and  among  them,  that  of  congenital  luxa- 
tion of  the  head  of  the  femur,  we  should  be  inclined  to 
refer  to  a  morbid  condition  of  the  nervous  system  or  cen- 
tres ;  and  the  proximate  cause,  or  that  which  most  obviously 
produces  the  displacement  of  the  parts,  to  a  pathological 
muscular  contraction,  which,  acting  as  the  unavoidable 
result  of  the  primary  disease,  with  more  or  less  activity 
and   diversified    combination,  ultimately  effects   the  entire 

dislocation  of  the  articulating  surfaces 

The  existence  of  a  state  of  disease  which    may  have    an 
influence    so    extensive   over    the   whole   muscular    sys- 


s\  mi-Tom  itoloqi  1 25 

tern,  or  be  limited  t<>  ;i  particular  portion  onh  of  it, 
ni;i\  enable  the  pathologisl  to  attribute  to  one  common 
source,  the  origin  <>l  numerous  maladies  which  formerly 
were  referred  to  as  mam  differenl  causes,  and  from  data 
now  known  we  can  thus.  I>\  generalization,  simplih  and 
reduce  to  a  unity  of  origin  the  whole  class  of  those  defor- 
mities of  the  human  shape  which,  as  a  resuli  <>i  morbid 
muscular  action,  take  place  at  the  articulations  in  the 
shape  of  club-toot,  distortions  of  the  spine,  torticollis, 
congenital  luxations,  &c. 

"  But  congenital  luxation  of  the  head  of  the  lemur 
upon  the  ilium,  although  caused  primarily,  as  we  believe, 
by  this  dynamic  or  morbid  retraction  of  a  portion  of  the 
muscular  apparatus,  occurring  during  intra-uterine  life,  is 
also  subjected  to  causes  which  begin  to  act  only  after 
birth,  and  which  materially  modify  the  appearance  and 
extent  of  the  displacement  of  the  articulating  surfaces  in 
relation  to  the  age  of  the  individual  affected.  Thus,  in  this 
luxation,  the  head  of  the  bone  is  generally,  at  first,  placed 
near  the  confines  of  the  acetabulum,  resting  upon  its  mar- 
gin or  a  little  above  it,  but  as  soon  as  progression  begins 
to  be  performed,  the  superincumbent  weight  of  the  trunk 
carries  the  pelvis  downwards,  and  the  heads  ol  the  lemurs 
being  entirely  freed  from  their  natural  cavities,  and  having 
now  no  point  of  resistance  superiorly,  ascend  gradually 
upon  ih<'  external  iliac  fossae,  until  at  last,  as  adult  age 
approaches,    as    in    the    example    before     us,    the    pelvis    i^ 


126  SYMPTOMATOLOGY. 

wedged  down  between  the  upper  portions  of  the  ossa 
femoram,  and  the  superior  margins  of  the  great  trochan- 
ters are  found  almost  on  a  level  with  the  iliac  crests.  One 
of  the  primary  effects  of  the  pathological  contraction  of 
the  muscles  (as  exemplified  by  the  attenuated  state  of 
the  muscles  in  the  ordinary  forms  of  talipes),  is  a  dimi- 
nished nutrition,  which  gives  rise  to  a  kind  of  '  arret  de 
developpem.ent'  in  the  parts  affected.  The  osseous  struc- 
ture of  the  pelvis  increases  as  extra-uterine  life  advances, 
while  those  muscles  original!}  affected,  and  which  produced 
the  displacement,  suffering  still  from  this  impediment  to  their 
natural  development,  do  not  elongate  in  proportion  to  the 
increase  of  the  other  parts,  and  thus  also  when  the  head  of 
the  hone  has  once  escaped  beyond  the  limits  of  the  cotyloid 
cavity,  is  its  tendency  to  ascend  on  the  external  iliac  fossa, 

w 

promoted.     It  is  not  difficult  to  understand  that  the  physio- 
logical action  also  of  the  muscles  acting  in  the  direction  of 
the  displacement,  will  have  a  tendency  to  induce  a  farther 
removal    of   the   head   of    the   bone    upwards ;    and   that 
the    muscles,    towards    the   internal    part  of   the    thighs, 
such  as  the  long  adductors,  semi-membranosus,   semi-ten- 
diuosus,  &c,  having  changed  their  angle  of  insertion,  will, 
during  the  progressive  movements  of  the  inferior  extremi- 
ties, aci  upon  the  ossa  femorum  so  as  to  throw  the  head  of 
each  upwards  and   somewhat  outwards.      These  auxiliary 
causes,  viz.  the  weight  of  the   body,  the   impeded   growth 
of  the   muscles  affected,    and  the  physiological   action  of 


SYMPTOMATOLOGY.  127 

the  muscles,  taking  effect  only  after  extra-uterine  life  lias 
begun,  readily  account  for  the  transposition,  in  chm-s  <>t' 
congenital  luxation  of  the  hip-joint  as  well  as  in  the 
other  affections  of  this  class,  occurring  in  a  gradual  man- 
ner, and  becoming  in  the  course  of  time  more  marked, 
after  these  various  causes  of  displacement  have  fully 
exerted  their  combined  influences. 

"  Having  said  thus  much  at  present  in  relation  to  the 
symptoms,  diagnosis,  and  cause  of  the  congenital  luxation 
of  the  head  of  the  femur  upon  the  dorsum  ilii,  I  shall 
recur  at  a  future  time  to  the  pathological  appearances 
observed  upon  post-mortem  examination,  and  the  thera- 
peutic means  which  have  been  adopted  to  remedy  the 
deformity  or  palliate  its  inconveniences." — London  Lan- 
cet, 1844,  No.  27,  vol.  I. 


\  3 


..  y  y~i-  ■ 


EXPLANATION  OF  PLATE    No.  V  . 

This  figure  represents  a  range  of  salient  points,  indicating  the  normal  position 
of  the  head  of  the  Femur.     In  cases  of  traumatic  dislocation  of  the  femur,  or  in 

congenital  displacement  of  the  head  of  this  bone,  where  there  is  obscurity,  this  diag- 
nostic sign  may  be  made  available. 

The  plate  gives  a  side  view  of  the  fetal   pelvis,  about  the  end  of  the  ninth  month, 
with  the  femur  flexed  upon  the  pelvis,  and  slightly  adducted. 

a.  Anterior  Superior  Spinous  Process  of  the  Ilium. 
6.  The  prominent  point  of  the  tuberosity  of  the  Ischium. 
c.  Tin-  upper  margin  of  the  Trochanter  Major. 
X   A  lino  along  the  range  of  these  three  poiuts. 


13 


CHAPTER   V. 

DIAGNOSIS    OF     CONGENITAL    DISLOCATIONS     OF     THE      HEAD 
OF    THE    FEMUR. 

The  congenital  dislocation  of  the  head  of  the  femur 
upwards  and  outwards  upon  the  ilium,  has  probably  been 
mistaken  more  frequently  for  morbus  coxarius  than  for 
anv  of  the  other  diseases  which  are  met  with  at  the  ilio- 
femoral articulation.  The  hip-disease,  as  it  is  called.  is 
essentially  an  inflammatory  affection,  and  from  its  com- 
mencement  to  its  termination, — whether  in  resolution,  or  in 
ulceration  of  the  synovial  membrane,  cartilage,  ligaments, 
and  bones,  and  consequent  dislocation, — symptoms  of  ante- 
cedent or  present  phlogosis  can,  on  can  lul  examination, 
generally  be  detected  While  this  inflammatory  affection 
is  in  its  dormant  or  incipient  state,  as  a  general  rule, 
lameness  does  not  occur,  and  it  is  not  until  lame- 
ness has  manifested  itself,  in  what  is  termed  the  second 
stage  of  the  disease,  that  difficult}  ma\  arise  in  forming 
tin- correct  diagnosis  between   the  congenital   dislocation 


132  DIAGNOSIS. 

of  the    hip-joint    and    the    affection    known    as    morbus 
cox  a ri us. 

The  history  of  the  disease,  and  the  consideration  of 
the  constitutional  temperament  of  the  individual,  will 
serve  as  useful  information  to  the  surgeon,  when  about  to 
analyse  the  real  nature  of  a  doubtful  affection  at  the  ilio- 
femoral articulation.  It  is  unnecessary  to  recapitulate 
the  several  symptoms  which  have  been  enumerated  in  the 
preceding  chapter  as  pathognomonic  of  the  congenital 
dislocation  of  the  femur  upon  the  ilium ;  but  there  are  cer- 
tain characters,  standing  out  in  forcible  contrast  to  the 
symptoms  attendant  upon  the  hip  disease,  which  merit 
consideration.  A  knowledge  of  them  ought  to  preclude 
the  possibility  of  the  congenital  affection  being  mistaken 
for  the  other  disease  in  question. 

In  the  lameness  resulting  from  congenital  dislocation  of 
the  femur  upwards  and  outwards,  the  shortening  of  the 
limb,  which  from  the  first  can  generally  be  detected,  has 
not  been  preceded  by  pain  or  inflammatory  symptoms  of 
any  kind  ;  in  the  hip-disease,  on  the  contrary,  the  lame- 
ness, which  becomes  apparent  towards  the  latter  part  of 
the  first  stage  of  the  complaint,  is  unaccompanied  by  any 
perceptible  shortening  of  the  limb,  and  considerable  pain 
is  felt  when  any  motion  is  made  which  causes  increased 
pressure  of  the  head  of  the  bone  against  the  acetabulum, 
at  the  same  time  that  great  suffering  is  almost  always  experi- 
enced, which  is  generally  referred  to  the  region  of  the  knee  of 


DIAGNOSIS.  133 

the  affected  side.  In  congenital  dislocation,  flexion  oj  the 
joint  is  performed  with  greal  ease,  while  in  the  hip-dis- 
ease, the  same  movement  is  attended  with  pain,  and  the 
patient  shrinks  from  the  touch. 

In  congenital  luxation,  when  the  patient  is  laid  in  the 
recumbent  position,  the  deformit}  which  is  so  evident 
in  the  erect  attitude,  disappears,  and  the  head  of  the 
femur  on  the  affected  side,  can  be  pushed  upwards  or 
draw  n  downwards,  or  rotated,  without  causing  an}  uueasi- 
ness  :  whereas  in  bip-disease,  auj  attempt  to  elongate  bv 
forcible  traction  the  limb  of  the  diseased  side  is  attended 
with  great  pain. 

[n  hip-disease,  during  rotation  of  the  thigh  outwards, 
the  head  of  the  lemur  can  generally  he  felt  in  the  groin, 
occupying  its  natural  place;  in  congenital  luxation,  the 
head  and  trochanter  major  can  be  felt  above  the  acetabu- 
lum, on  the  surface  of  the  ilium,  while  a  palpable  vacuity 
exists  iu  the  groin,  opposite  the  acetabulum. 

In  hip-disease,  the  nates  becomes  Hat,  so  that  die  usual 
niche  between  the  buttock  and  the  thigh  is  effaced; 
while  in  the  congenital  affection,  this  furrow  is  present, 
although  situated  higher  up.  and  more  curved  outwards 
than  natural. 

Before  the  occurrence  of  spontaneous  dislocation — 
which,    as    a    result    of    ulceration    of    the    border    of    the 

acetabulum,  someti s  takes   place,  although    rarely,   in 

morbus  coxarius — the   thigh   being  flexed  al   righi  angles 


J  34  DIAGNOSIS. 

with  he  pelvis,  and  slightl)  adducted,  a  line,  drawn  from 
the  anterior  superior  spinous  process  of  the  ilium  to  the 
prominent  point  of  the  tuberosity  of  the  ischium,  will 
range  nearly  on  a  level  with  the  upper  margin  of  the  tro- 
chanter major;  while  in  congenital  luxation,  this  line 
would  pass  over  a  part  of  the  trochanter,  approaching 
more  or  less  to  its  base.      Vide  Plate   v. 

Although  there  is  much  lameness  in  congenital  luxa- 
tion, the  health  of  the  patient  does  not  directly  suffer  ; 
he  can  walk,  skip,  or  run  for  a  short  time  with  consider- 
able facility,  and  without  experiencing  pain  ;  whereas  in  hip- 
disease,  the  general  health  is  always  impaired,  and  the  acts 
of  locomotion  are  performed  with  much  difficulty  and  pain. 

In  hip-disease,  it  is  exceedingly  rare  for  the  malady  to 
occur  symmetrically  and  simultaneously  on  both  sides — a 
circumstance  which  is  of  common  occurrence  in  the  con- 
genital dislocation  of  the  femur. 

These  differential  signs,  in  connexion  with  the  pecu- 
liarity of  the  gait  and  attitude,  and  the  other  symptoms 
mentioned  in  the  previous  chapter,  as  observable  in  indivi- 
duals affected  with  congenital  dislocation,  exhibit  the 
pathognomonic  characters  of  the  two  affections  in  such  a 
distinct  manner,  the  one  from  the  other,  that  if  appre- 
ciated, the  error  of  mistaking  a  congenital  luxation  of  the 
coxo-femoral  articulation  for  morbus  coxarius  will  not  be 
likely  to  occur. 

In  cases  of  incipient  congenital  luxation,  or  as  it  has  been 


DIAGNOSIS.  I   15 

termed,  congenital  subluxation  of  the  femur,  where  the 
bead  of  the  bone  rests  on  the  margin  <»i  the  acetabulum,  ;i 
correct  diagnosis  will  necessarily  be  more  difficult  of  at- 
tainment, than  when  the  lemur  bas  ascended  higher  on 

the  dorsum  ilii. 

There  are  other  affections  which   niay  be  confounded 
with  congenital  displacement  of  the  femur. 

M.  Guerin  has  described  a  class  of  congenital  deformi- 
ties at  the  hip,  which  lie  lias  named  pseudo- luxations, 
because  they  offer  the  deceptive  appearance  of  positive 
luxations.  In  these,  however,  the  head  of  the  femur  is 
not  transferred  from  the  cotyloid  cavity.  Pseudo-luxa- 
tions at  the  hip  present  two  varieties,  one  simulating  a 
dislocation  of  the  femur  backwards  and  outwards  ;  the 
other,  a  dislocation  of  the  hone  downwards  and  for- 
wards. This  kind  of  deformity  consists  in  a  permanent 
abnormal  direction  of  the  members,  referable,  as  its  cause, 
to  morbid  muscular  retraction,  which,  however,  is  exerted 
in  a  degree  not  sufficiently  intense  to  produce  the  exarti- 
culation  of  the  head  of  the  femur.  Pseudo-luxations  are 
allied  only  to  congenital  luxations,  in  having  a  common 
cause  for  their  origin,  and  in  presenting  a  kind  of  similarity 
in  the  external  appearance  of  the  deformity.  The  first 
variety    of    the    pseudo-luxations    mentioned    ahove,    ma\ 

simulate  somewhat   the  congenital  luxation   of  the  femur 
upon  the  ilium.* 

•  These  pseudo-luxations,  with  other  deformities  From  muscular  retraction  :i!><.>ut 
ili<  nip-joint,  are  alluded  to  by  Delpeoh,     Vide  I'Orthomorphie. 


136  DIAGNOSIS. 

There  are  certain  alterations  in  the  head  and  neck  of 
the  thigh  bone,  and  of  the  acetabulum,  which  may  also 
give  rise  to  some  doubt  in  forming  the  diagnosis  of 
this  congenital  dislocation.  We  find  that  Palleta 
speaks  of  several  malformations,  which  may  resemble  this 
affection;  such  as  an  unusual  enlargement  of  the  acetabu- 
lum, permitting  a  vacillating  motion  of  the  head  of  the 
femur;  a  malformation  of  the  upper  extremity  of  the 
femur,  where  the  head  and  neck  are  in  part  atrophied, 
and,  as  it  were,  fused  with  the  trochanter  major  which 
rises  above  them ;  an  exostosis  springing  from  the  bot- 
tom of  the  acetabulum,  and  changing  the  natural  relations 
of  the  femur ;  and  an  atrophy,  manifesting  itself  upon 
one  half  of  the  pelvis  and  upon  the  inferior  extremity  of 
the  same  side. 

Mr.  Liston  mentions  a  curious  case  of  malady  of  the 
hip-joint,*  of  a  young  infantry  soldier,  who  died  of  pul- 
monary consumption  after  two  years'  confinement  in  the 
General  Hospital  at  Chatham.  In  this  case,  the  head  of 
the  bone  was  found  approximated  to  the  shaft,  owing  to 
absorption  of  the  neck,  without  any  ulceration  of  the 
articular  cartilage.  "  Previously  to  his  admission,  he  had 
regularly  performed  his  duty,  from  which  it  is  plain  that 
his  limbs  were  then  of  equal  length,  although  wheu  his 
body  was   examined,  the  affected  femur   was  upwards  of 

*  Liston's  Surgery — report  of  acase  of  Mr.  Gulliver's. 


DIAGNOSIS.  137 

o/n  inch  and  a  half  shorter  than  the  other.  From  a 
careful  inquiry,  after  his  death,  ii  appeared  that  he  had, 
five  years  previously,  fallen  on  the  trochanter,  in  conse- 
quence of  which  he  often  complained  of  pain  in  the  hip, 
but  continued  to  do  his  duty  long  after,  never  having  been 
confined  on  account  of  the  accident/'4'  The  shortening 
of  the  limb  in  this  case  is  attributed  to  the  accident,  and  to 
the  long  confinement  with  the  pulmonary  malady,  which 
ultimately  proved  fatal. 

Sir  Benjamin  Brodie  has  noticed  that  the  lower 
extremities  are  sometimes  of  unequal  length,  from  origi- 
nal conformation  ;  the  femur,  tibia  and  fibula  of  one  side 
being  shorter  than  these  bones  of  the  other  side. 

In  aged  persons,  the  neck  of  the  femur  becomes  some- 
times altered  by  interstitial  absorption,  causing  an  unna- 
tural shortening  of  the  inferior  extremities ;  and  this  cir- 
cumstance predisposes  in  a  remarkable  degree  to  fracture 
of  the  neck  of  the  femur,  accompanied  by  still  farther 
shortening  of  the  limb. 

Delpechf  has  mentioned  an  osseous  malformation 
causing  lameness,  most  probably  depending  on  a  rachitic 
condition,  where  there  is  malposition  of  the  acetabula 
either  more  forwards  or  more  backwards  than  natural. 
The  same  surgeon  also  mentions  an  atrophied  state  of 
the  halves   of  the  sacrum   and   of  the   ilium,  as  causing 

•  Liston's  Surgery — report  of  a  case   of  Mr.  Culliv.  rV 
t  Delpech,  l'Orthomorphic. 

10 


138  DIAGNOSIS. 

lameness ;  and  M.  Gerdy  has  described  several  anomalies 
of  the  upper  extremity  of  the  femur,  from  which  a  limp- 
ing gait  is  produced,  where  the  neck  of  this  bone  is 
inserted  at  a  greater  or  less  distance  from  the  trochanter 
major,  and  in  a  direction,  sometimes  inclining  obliquely 
forwards  ;  at  others,  obliquely  backwards. 

All  these  morbid  affections  may  simulate,  more  or  less, 
the  congenital  luxation  of  the  head  of  the  femur.  A 
knowledge  of,  and  familiarity  with  their  existence,  and 
the  application  to  them  of  the  signs  which  have  been 
enumerated  and  described  for  determining  the  pathogno- 
monic characteristics  which  accompany  congenital  dislo- 
cation of  the  femur  upon  the  ilium,  will  enable  the  sur- 
geon to  arrive  with  great  certainty  at  a  just  differential 
diagnosis. 


139 


CHAPTER  VI. 

PROGNOSIS    OF    CONGENITAL     DISLOCATIONS    OF     THE     HEAD 
OF    THE    FEMUK. 

In  congenital  dislocations  of  the  femur,  much  di- 
versity of  opinion  has  existed  in  regard  to  the  pos- 
sibility of  effecting  permanent  reduction  by  the  efforts 
of  art.  Dupuytren  supposed  that  it  was  useless  to 
attempt  the  permanent  adjustment  of  the  articulation, 
and  confined  his  treatment  simply  to  ameliorating  mea- 
sures. 

Of  late  years  science  has  advanced  a  step  farther  in 
this  matter,  and  cases,  successfully  treated,  of  congenital 
dislocation  of  the  femur,  are  recorded,  which  place  beyond 
a  doubt  the  possibility  of  reducing  fixedly  the  head  of 
the  femur  at  the  cotyloid  cavity. 

The  difficulties,  however,  attendant  upon  the  treatment 
of  this  affection  arc  great,  and  the  altered  condition  oi 
the  component  parts  of  the  articulation,  which  i^  apt  to 
take  place  even  in  early  life,  as  well   as  ol    the  other  lis- 


140  PROGNOSIS. 

sues  surrounding  the  ilio-femoral  articulation,  render  this 
displacement  one  of  the  most  formidable  maladies  to 
which  the  articular  apparatus  of  the  body  is  liable  ;  the 
surgeon  then  should  be  guarded  in  giving  a  prognosis 
which  might  be  too  favorable  as  regards  the  facility  of 
reduction,  or  the  certainty  of  a  rapid  and  permanent 
cure. 

It  is  certain  that  after  middle  life,  the  relative  confor- 
mation of  the  acetabulum,  and  of  the  head  of  the  femur, 
as  well  as  of  the  articular  capsule,  are  so  entirely  changed, 
that  a  reciprocal  adjustment  between  these  component 
parts  of  the  joint  is  beyond  the  reach  of  surgery.  A 
more  favorable  prognosis  may  be  given,  when  the  requi- 
site treatment  is  adopted  in  early  life. 

The  curability  of  congenital  dislocations  of  the  femur, 
and  the  principles  upon  which  their  treatment  has  been 
founded  and  attempted,  will  be  spoken  of  in  detail  in  a 
following  chapter. 

It  has  been  stated  that  the  single  luxation  of  the 
head  of  the  femur  upon  the  ilium  is  more  serious 
in  its  nature,  from  the  fact,  that  in  this  form,  the  dia- 
meters of  the  pelvis  are  more  deranged,  than  when  the 
luxation  is  double.  I  do  not  believe  there  is  much  differ- 
ence in  this  respect,  in  either  case,  as  regards  the 
impediment  which  will  be  presented  during  parturition, 
to  the  passage  of  the  child,  from  defective  space  in  some 
of  the  measurements  of  the  pelvis. 


PROGNOSIS.  1  I  I 

lii  cases  where  females,  suffering  from  this  displace- 
ment, have  become  pregnant,  I  think  thai  pathological 
investigation  will  justify  the  expression  of  an  unfavorable 
prognosis  in  regard  to  the  probable  facility  or  safety  of 
the  process  of  parturition.  From  the  dissections  I  have 
made  of  persons  who  had  been  affected  with  congenital 
dislocation  of  the  hip,  I  cannot  doubt  that  the  diameters 
and  measurements  of  the  pelvis,  in  cases  either  of  the 
double  or  single  form  of  this  affection,  are  so  modified 
and  changed  as  to  he  most  unfavorable  for  the  passage  of 
the  head  of  the  child  through  its  two  straits,  Dupuytren, 
whose  great  authority  always  merits  attention,  has  ex- 
pressed himself  in  the  following  words,  asserting  that  the 
pelvis  retains  its  natural  dimensions  and  conformation  : 
"  II  est  a  remarquer  que  les  phenomenes  qui  ont  lieu  a 
l'exterieur  du  bassin  n'in  fluent  en  rien  sur  le  developpe- 
ment  de  cette  cavite,  et  qu'avant  l'epoque  de  la  puberte,  pen- 
dant cette  epoquc,  et  apres  quelle  est  passee,  le  bassin 
acquiert  les  dimensions  les  plus  favorables  a  Pexercice  des 
fonctions  des  visceres  qu'il  renferme;  et  qu'il  est  aussi  propre 
a  recevoir,  a  conscrver  et  a  transmettre  le  produil  de 
la  fecondation  que  chez  les  personnes  les  mieux  con- 
formees." 

The  facts  occurring  from  autopsic  examinations  go 
directly  to  refute  the  statement  of  Dupuytren.  Ii\ 
a    reference  to    Plates    Nos.    vi.,    vii.,    viii.,    and     i\.. 


142  PROGNOSIS. 

and  the  description  of  the  cases  which  they  repre- 
sent, it  will  be  seen  that  in  these  specimens,  the 
pelvic  diameters  are  entirely  altered  from  their  natural 
standard. 


littu .  ofS^'O'i-  k  M<ye>- 


EXPLANATION  OF  PLATE   No.  VI. 

Front  view  of  a  dissection  of  a  female  pelvis,  with  Double  Congenital  Disloca- 
tion of  tho  Femurs  upon  the  Dorsa  of  the  Ilia. 

a.  Anterior  and  Superior  Spinous  process  of  tho  Ilium. 

b.  Trochanter  Major. 

c.  Trochanter   Minor. 

d.  Anterior  part  of  tho  Original  Capsular  Ligament. 

e.  The  Original  Capsule  laid  open. 

f.  Tho  Annular  Opening,  by  which  the  Head  of  the  Femur  escaped  upon   the 

Dorsum  Ilii. 

g.  Tho  Original  Acetabulum,  become  now  triangular. 

h.  The  cavity  of   tho    Original  Capsule  laid    open    by    removal  of   its  Anterior 
Wall. 

i.  Tho  Neck  of  tho    Femur    grasped    by  the   Annular  Opening   in  tho  Capsule 
through  which  the  Head  passed. 


Z  ith.  of  Ja.v«/  *  Mnji 


EXPLANATION  OF  PLATE  VI! 

Posterior  view  of  a  dissection  of  the  same  pelvis,  with  Double  Congenital  Dislo- 
cation of  the  Femurs  upon  the  Dorsa  of  the  Ilia. 

a.  Tho  Crest  of  the    Ilium. 

b.  The   Dorsum   Ilii. 

c.  Posterior  surface  of  the  new  Capsule  entire. 

d.  Trochanter  Major. 

e.  Trochanter  .Minor. 

/.  Head  of  the  Femur  lying  in  the  now  Capsule. 
g.  Now  Capsule  laid  open,  showing  its  interior. 


147 


CHAPTER  VII. 

PATHOLOGY    OF    CONGENITAL    DISLOCATIONS    OF    THE   HEAD 
OF    THE    FEMUR. 

Except  in  cases  of  foetal  monstrosities,  instances  of 
congenital  dislocation  at  the  ilio-femoral  articulation,  are 
not  met  with  in  any  other  form,  than  that  in  which  the 
head  of  the  femur  is  exarticulated  from  its  socket,  and 
passes  upon  the  external  surface  of  the  ilium. 

Another  variety,  under  the  name  of  a  subluxation 
upwards  and  backwards,  has  been  mentioned,  where  the 
head  of  the  femur  has  not  yet  entirely  cleared  the  mar- 
gin of  the  acetabulum.  This  variety  appears  to  be  only 
the  initiatory  stage  of  the  dislocation  upon  the  dorsum  of 
the  ilium,  and  I  shall  only  regard  it  as  such.  In  fact, 
the  head  of  the  femur,  to  ascend  on  the  ilium,  most  slip 
out  of  its  socket,  at  the  posterior  portion  of  the  acetabu- 
lum, where,  in  the  foetus,  there  is  a  space  unoccupied  by 
bone.  A  depression  thus  exists  on  the  pourtour  of  the 
acetabulum,  between  the   ilium  and  ischium,  occupied  in 


148  PATHOLOGY. 

the  recent  subject  by  cartilage  only  ;  the  deepest  part  of 
which,  in  the  skeleton,  is  almost  on  a  level  with  the  bot- 
tom of  the  acetabulum.  It  must  be  recollected  also,  that 
the  thighs  are  generally  flexed  upon  the  abdomen  before 
birth,  and  that  after  the  head  of  the  femur  has  once 
passed  the  posterior  margin  of  the  cotyloid  cavity,  the 
mere  act  of  extension  of  the  thigh  after  birth,  will  induce 
the  head  of  the  femur  to  describe  a  segment  of  a  circle 
upwards  in  the  direction  of  the  dorsum  ilii. 

It  has  been  supposed  that  in  attempts  to  reduce  the 
congenital  dislocation  of  the  femur  upon  the  ilium,  the 
head  of  the  bone  has  been  thrown  into  the  ischiatic 
notch.  This  seems,  however,  to  be  only  the  result  of  the 
application  of  mechanical  force,  and  the  head  of  the 
femur  does  not  appear  to  have  been  found  primarily  in 
this  position. 

The  morbid  appearances  to  be  met  with  in  this  luxa- 
tion, on  autopsic  examination,  vary,  according  to  the 
age  of  the  individual,  and  to  the  extent  of  the  altera- 
tions which  may  have  occurred  in  the  tissues  at,  or  in 
contiguity  to  the  ilio-femoral  articulation  ;  but  there 
are  pathological  characters  which  are  common,  amid 
the  numerous  changes  which  take  place  in  the  liga- 
mentous and  osseous  structures  of  the  joint,  as  well  as 
in  the  soft  parts  by  which  it  is  surrounded. 

If  the  examination  of  this  displacement  be  made  dur- 
ing the  foetal  period,  or  when  extra-uterine  life  has  been 


P  LTHOLOGY.  L49 

of  short  duration,  the  (Styloid  cavitj  is  round  to  be  but 
little  altered  in  its  normal  shape  and  dimensions,  and  to 
retain  the  capacity  of  receiving  the  head  of  the  femur. 
The  period  of  life  ;u  which  the  cotyloid  c;i\ii\  begins  to 
assume  an  alteration  of  shape  and  of  dimensions  is  nol 
the  same  in  all  cases;  it  is  probable, however,  thai  beyond 
the  twelfth  or  fourteentb  year  of  age,  the  changes  which 
this  cavitj  has  undergone,  have  so  far  destroyed  the  nor- 
mal relations  of  the  joint,  that  reciprocal  adaptation  would 
be  impossible. 

The  acetabulum,  surmounted  by  its  fibrous  border,  at 
the  earlier  periods  of  this  displacement,  is  generally  found 
to  present  a  depression  on  the  superior  and  posterior  part 
of  its  margin  ;  and  a  kind  of  adipose  tissue,  probably  the 
degenerated  and  hypertrophied  soft  structure  belonging  to 
the  cavity,  is  sometimes  found  to  a  greater  or  less  extent, 
occupying  the  acetabulum,  in  place  of  the  head  of  the 
lemur. 

The  head  of  the  femur  now  rests  upon  the  margin  of 
the  acetabulum,  or  upon  the  ilium  near  its  circumference, 
and  presents  hut  little  deformity,  retaining  its  hemi- 
spherical appearance,  except  upon  its  inner  aspect,  where 
it  is  sometimes  flattened,  from  resting  upon  the  ilium. 

The  capsular  ligament  is  elongated,  as  also  the  liga- 
mentum  teres;  the  structural  integrity  of  both,  however, 
is  still  maintained,  and  the  capsule  at  this  early  period 
has  been  said  to  resemble  an  hour-glass,  large  at  its  pelvic 


150  PATHOLOGY. 

and  femoral  attachments,  and  small  at  its  centre.  The 
capsule  is  put  upon  the  stretch  by  the  ascent  of  the  head 
of  the  femur,  which  is  still  kept  from  direct  contact  with 
the  external  surface  of  the  os  ilium  by  an  intervening  layer 
of  the  capsule. 

The  synovial  secretion  is  found  to  exist  sometimes  in 
its  natural  condition. 

This  may  be  said  to  be  the  usual  appearance  in  the 
early  stage  of  this  displacement ;  still  exceptions  may 
occur,  as  appears  from  a  case  already  quoted  from  Palleta, 
on  pages  19  and  20,  of  a  child  two  years  of  age,  where 
alteration  had  taken  place  at  this  early  period  of  the 
affection,  in  nearly  all  the  parts  of  the  articular  apparatus 
of  the  hip-joint ;  but  in  this  instance  there  is  reason  to 
suppose  that  the  head  of  the  femur  had  become  entirely 
detached,  which  would  render  the  real  nature  of  that  case 
somewhat  doubtful. 

In  proportion  to  the  duration  of  the  dislocation,  and  to 
the  more  or  less  advanced  period  of  life,  the  nutrition  of 
the  parts,  from  various  causes,  being  materially  disturbed, 
the  structural  changes  in  the  various  tissues  become  also 
more  marked. 

The  separation  between  the  acetabulum  and  the  head 
of  the  femur  becomes  gradually  greater,  owing  to  the 
progressive  ascent  of  the  latter  upon  the  ilium. 

The   Cotyloid  Cavity,  in   the  progress  of  the  affec- 


PATHOl  OGY.  L5J 

tion,  lends  to  become  contracted,  and  to  assume  an  oval  or 
even  a  triangular  shape,  approximating,  ;i^  ii  were,  to  the 
primitive  form  of  the  acetabulum  daring  foetal  life,  before 
its  three  component  parts  have  arrived  at  the  period  of 
osseous  consolidation.  The  acetabulum  remains  sometimes, 
however,  nearly  circular,  and  presents  upon  its  upper  semi- 
circumference  a  depression  of  a  somewhat  cresccntic  form, 
which  allows  the  head  of  the  femur  to  pass  to  and  fro 
from  the  dorsum  of  the  ilium  into  its  original  receptacle, 
now  deprived  of  its  cartilaginous  lining.  This  was  the 
condition  in  one  of  the  cases  of  congenital  luxation,  of 
which  I  had  an  opportunity  of  making  a  post-mortem 
examination.  This  subject  was  a  female,  about  fifty 
years  of  age.  The  head  of  the  femur  had  passed  through 
the  upper  part  of  the  capsular  ligament,  and  rested  upon 
the  external  surface  of  the  ilium,  about  an  inch  from  the 
border  of  the  acetabulum.  A  semicircle  of  new  osseous 
material  springing  from  the  ilium,  towards  forming  a  new 
acetabulum,  prevented  the  femur  from  ascending  farther 
in  this  direction.  The  cotyloid  cavity,  although  uearly 
circular,  had  become  more  shallow,  but  was  sufficiently 
large  to  allow  the  head  of  the  femur,  which  was  not 
much  under  the  natural  si ze,  to  pass  into  it.  Owing  to 
the  disappearance  of  a  lunated  portion  of  the  upper  cir- 
cumference of  the  acetabulum,  the  head  of  the  femur 
could  readily  pass  from  this  cavity  upon  the  ilium,  and 
reduction  could  thus  easily  be  effected,  but  in  this  condi- 


I  5"2  PATHOLOGY. 

tioii  of  the  parts,  it  could  never  have  been  rendered  per- 
manent. 

Sometimes  the  cotyloid  cavity  is  filled  up  with  cellulo- 
osseous  material,  readily  yielding  to  the  pressure  of  a 
pointed  instrument. 

In  one  of  the  cases  I  have  described  farther  ou,  it  will 
be  seen  that  the  acetabula  had  assumed  a  contracted  tri- 
angular shape,  and  were  nearly  filled  up  with  softish 
adipo-osseous  tissue.      Vide  Plate  vi. 

In  another  case,  the  acetabula  were  found  contracted  to 
a  cavity  still  smaller  than  in  the  previous  instance,  and 
were  filled  entirely  with  a  semi-osseous  tissue  of  a  similar 
character  to  that  before  mentioned.      Vide  Plate  vii. 

The  Head  of  the  Femur  becomes  altered  to  as  great 
an  extent  as  the  cotyloid  cavity,  and  the  neck  also  soon 
participates  in  the  progressive  alterations. 

The  head  loses  its  spherical  appearance,  and  becomes 
changed  in  its  dimensions  and  texture.  The  articular 
cartilage,  with  which  it  is  invested,  having  lost  its  rela- 
tions with  the  articulating  surface  of  the  acetabulum,  and 
not  being  naturally  supplied  with  the  synovial  fluid,  or 
with  its  usual  amount  of  vascular  nutrition,  gradually 
undergoes  mutations  which  lead  to  its  ultimate  disappear- 
ance, particularly  where  the  head  comes  in  direct  contact 
with  the  osseous  tissue  of  the  ilium.  The  aspect  of  the 
head,    where   the   round    ligament  ought   to   be    inserted, 


PATHOLOGY.  I  53 

often  presents  a  flattened  surface,  denuded  of  its  articular 
cartilage,  a  thin  brittle  shell  of  bone  only  covering  the 
deteriorated  cancellated  interior  structure  of  the  head. 
The  neck  of  the  femur  is  also  small,  short,  and  stunted, 
and  assumes  a  more  horizontal  direction  to  the  axis  of  the 
femur  than  is  usual,  the  head  being  more  on  a  level  with 
the  trochanter  major,  and  losing  its  normal  obliquity  in 
relation  to  the  shaft  of  the  bone.  Vide  Plates  vi. 
and  vii. 

The  consistence  of  the  osseous  tissue  of  the  head  is 
very  considerably  changed,  being  brittle  and  softer  than 
natural,  and  presents  the  evidences  of  perverted  or  dimi- 
nished nutrition. 

In  some  instances,  where  the  displacement  has  been  of 
long  standing,  the  head  and  neck  are  found  to  have 
entirely  disappeared;  the  ligamentous  connexions  between 
the  pelvis  and  the  femur  being  attached,  on  the  femoral 
side,  to  the  trochanter  major  or  to  the  upper  portion  of 
the  shaft  of  the  bone.  This  disposition  of  the  parts  is 
represented  on  Plates  viii.  and  ix. 

The  head  and  neck  of  the  femur  may  assume  in  this 
affection  various  shapes  and  degrees  of  deformity,  from 
the  simple  changes  which  take  place  in  earlj  life,  up  to 
their  complete  atrophy  and  disappearance  which  occur 
sometimes  in  old  age. 

This  will  not  seem  extraordinary,  when  it  is  consi- 
dered  that  the  head  of  the  femur  is  peculiarly  situated   in 

11 


154  PATHOLOGY. 

regard  to  its  vessels  of  nutrition,  which  chiefly  pass  to 
its  structure  by  means  of  the  round  ligament,  which 
is  attached  upon  its  inner  aspect.  The  head  of  the 
femur  is  not  ossified  for  some  time  after  birth,  and  being 
isolated  from  the  shaft  by  intervening  cartilaginous 
tissue  at  the  early  periods  of  life,  it  receives  no  arterial 
supply  from  the  vessels  distributed  through  the  other  por- 
tions of  the  os  femoris,  and  but  little  from  those  ramifying 
in  the  contiguous  investing  periosteum.  From  the  nature 
of  the  displacement,  the  ligamentum  teres  must  be  unduly 
stretched  in  the  very  commencement  of  the  luxation,  and 
the  arteries  coursing  along  it,  more  or  less  compressed. 
When  this  circumstance,  and  even  the  total  destruction  of 
the  round  ligament,  which  frequently  takes  place,  is  taken 
into  consideration,  it  can  easily  be  understood  how — particu- 
larly after  the  protracted  existence  of  this  affection  during 
the  course  of  many  years — the  nutrition  of  the  head  may 
become  so  perverted  as  to  produce  structural  deteriora- 
tions, terminating  sometimes  in  its  total  disappearance. 
In  the  case  represented  on  Plates  vii.  and  nil.,  it  will 
be  observed  that  the  round  ligament  had  entirely  dis- 
appeared. 

It  is  also  possible,  even  in  the  early  years  of  this  dis- 
placement, for  the  head  of  the  femur,  before  it  is  ossified, 
to  become  detached  from  the  shaft,  from  the  effects  of 
violence  or  of  friction,  and  its  early  disappearance  may 
in  this  manner  be  accounted  for.     It  is  difficult  to  explain 


PATHOLOGY.  1  55 

the  condition  of  the  upper  part  of  the  femur,  in  the  case 
described  l>\  Palleta,  and  already  referred  to,  of  a  child 
two  years  of  age,  in  which,  he  says,  "femur,  pene  dixe- 
rim,  acepkalum  Juit"  except  upon  the  supposition,  that 

the  cartilaginous  head  of  the  femur  had  thus  become  de- 
tached. 

The  Capsular  Ligament  and  the  Ligamentum  Teres 
are  found  also  to  present  various  phases  and  alterations.    As 
a  natural  consequence  of  the  ascent  of  the  head  of  the 
femur    upon    the  dorsum    ilii,  the   capsule  must   become 
e/ongated   and   stretched   beyond  its  normal   dimensions. 
The  extent  of  the  pelvic  and  femoral   attachments  will 
prevent    the  two  extremities  of   the  capsule   from   coal- 
escing, but  towards  its  middle  portion,  the  walls  approach, 
producing   a  contracted  appearance  at   this   part,  so  that 
the  capsule   in   the  primary  stages  of  the   malady,  before 
it  has  given  way  in  its  continuity,  has  been  compared,  as 
already  stated,  to   an   hour-glass,  large   at  each   end  and 
contracted    in   the    middle.       The    round    ligament    also 
becomes  stretched  and  more  slender,  and  is  embraced  by 
the    central    contracted  portion    of  the    capsule  through 
which  it  must  extend  while   it  remains  unbroken. 

The  articular  capsule  mav  retain  tor  many  years  its 
integrity,  the  head  of  the  femur  playing  upon  the  dorsum 
ilii  during  progression,  a  layer  of  the  capsule  inter- 
vening between  the  head  and   the  external  surface  of  the 


156  PATHOLOGY. 

ilium.  At  length,  from  continued  friction  and  pressure, 
absorption  takes  place,  and  a  portion  of  the  wall  of  the 
capsule  gives  way,  so  as  to  allow  the  head  of  the  femur 
to  escape  from  its  cavity,  and  to  come  in  direct  contact 
with  the  osseous  structure  of  the  dorsum  ilii.  This  state 
of  things  may  exist  lor  a  longer  or  shorter  period  ;  the 
head  of  the  femur  passing  to  and  fro  between  its  original 
capsule  and  the  external  surface  of  the  ilium.  The  ace- 
tabulum, however,  having  now  lost  its  normal  configura- 
tion, permanent  reduction  is  scarcely  attainable.  When 
the  capsule  has  been  perforated,  so  as  to  allow  the  head  to 
escape  from  it,  the  ligamentum  teres,  becoming  elongated 
and  slender,  must  give  way,  and  soon  disappears.  This 
ligament,  in  the  early  stage  of  the  displacement,  is  gene- 
rally found  to  retain  its  continuity.      Vide  Plates  vi.  and 

VII. 

The  capsule  and  ligamentum  teres,  as  would  appear 
from  one  of  the  dissections,  hereafter  more  particularly 
described,  may  coalesce  in  proportion  to  the  disappear- 
ance of  the  head,  and  form  a  strong  ligamentous  cord, 
running  between  the  pelvis  and  the  upper  portion  of  the 
femur.      Vide  Plates  viii.  and  ix. 

New  Capsule. — When  the  head  of  the  femur  has 
escaped  from  its  natural  capsule,  and  become  placed  in 
contact  with  the  surface  of  the  os  ilium,  a  new  set  of 
phenomena  takes  place.     Reparatory  efforts  are  made  to 


PATHOLOGY.  107 

restore  the  head  of  the   bone  to  something  like  its  former 

condition,   and  nature  attempts  to   form  a  new  capsular 
ligament,  which  on   the  one  hand  is  attached  to  the  dor- 
sum   and   contiguous   portion   of  the   ilium,   and   on    the 
other,  to   the  outer   and  posterior  surface  of  the  old   cap- 
sale,  and  to  the  margin  of  the  perforation    through  which 
the    head  of   the  femur  had     made  its  escape.      (Vide 
Plates  vi.   and   vn.)     Or,    the    head    may    never    have 
escaped  upon  the  ilium,  and  in  that  case,  in  proportion  as 
the  head   becomes  atrophied   and  disappears,  the  sides  of 
the  old  capsule   become  coalesced  and  glued   together,  as 
previously  remarked.     To  the  posterior  part  of  the   cord 
thus  formed,  a  set  of  radiating   fibres,  springing   from  the 
dorsum  of  the    ilium,    become    attached,   and   fortify    it. 
These     fibres     probably   represent,    in    another  form,    a 
recent  capsule,  which,  under  other  circumstances,  as  when 
the  head  has  pierced  the  old  capsule  and  rests  upon  the 
dorsum  ilii,  would  assume  a  regular  capsular  form.      Vtdt 
Plates  viii.  and  ix.. 

New  Acetabulum  or  Socket. — By  the  formation  of 
the  new  capsule,  a  false  articulation  is  parti)  accom- 
plished, which,  to  be  complete,  requires  a  new    arrange- 

nt    upon   the  dorsum  of  the  ilium,  to  represent    a  new 

acetabulum.  This  end  is  attained  in  two  different  ways. 
In  one,  there  is  a  simple  glenoid  depression  scooped  out, 
as  it  were,  upon  the  dorsum   of  the  ilium.     { \'i<L    Plate 


158  PATHOLOGY. 

vii.)  In  the  other,  nature  increases  her  efforts,  and,  as 
often  happens  after  traumatic  dislocations,  new  osseous 
matter  is  thrown  out  upon  the  ilium,  which,  at  times, 
assumes  to  some  extent  the  cup-like  form  of  an  acetabu- 
lum. In  the  first  case,  the  new  capsule  attaches  itself  to 
the  margin  of  the  depression  (vide  Plate  vii.)  ;  in  the 
second,  to  the  osseous  border  of  the  new  socket. 

M.  Guerin  has  stated  that  it  was  an  invariable  sequent, 
for  a  new  osseous  socket  to  be  thrown  out  upon  the  dor- 
sum ilii,  as  soon  as  the  head  of  the  femur,  in  congenital 
dislocations  of  this  bone,  has  escaped  from  the  articular 
capsule,  and  becomes  placed  in  circumstances  somewhat 
similar  to  those  attendant  upon  the  traumatic  dislocation 
of  the  femur,  and  he  has  founded  a  theory  of  treat- 
ment upon  this  supposed  fact.  The  formation  of  a  new 
socket  by  osseous  effusion,  is  not  an  invariable  result  of 
the  perforation  of  the  articular  capsule  and  the  escape  of 
the  head  of  the  femur.  The  drawings  of  a  pelvis,  now 
in  my  possession,  establish  the  presence  of  only  a  simple 
depression  upon  the  dorsum  of  the  ilium,  notwithstanding 
that  the  head  of  the  femur  has  on  both  sides  passed 
through  a  large  aperture  at  the  upper  part  of  the  capsule, 
and  has  become  placed  in  immediate  contact  with  the 
osseous  structure  of  the  ilium.      Vide  Plate  vii. 

The  secondary  depressions,  or  the  sockets,  intended  to 
hold  a  certain  relation  with  the  displaced  head,  after  it 
has  passed  from  its  original   capsule,  are  generally  lined 


PATHOLOGY.  I. '/.» 

by  a  thin  layer  of  tissue,  depending  probably  upon  the 
periosteum  of  the  ilium  ;  and  this  may  at  times  present  a 
smooth  surface,  somewhat  analogous  to  the  sj  aovial  mem- 
brane. At  other  times,  from  age  and  continued  friction, 
an  appearance  of  eburnation  is  present ;  at  others  again, 
a  rough  surface.  The  osseous  tissues  of  the  pelvis  and 
of  the  femur,  when  thus  deprived  of  the  intervention  of 
any  soft  tissue,  come  into  immediate  contact,  and  when 
moved  upon  each  other,  produce  a  harsh  grating 
sound. 

Another  modification  which  the  capsule  is  seen  to 
assume,  is  represented  in  Plates  viii.  and  ix.  The  head 
of  the  bone,  in  this  case,  has  never  escaped  from  the  cap- 
sule, but  has  become  absorbed,  and  the  walls  of  the  cap- 
sule coalescing,  have  finally  become  conglomerated  into 
a  firm,  dense,  ligamentous  cord,  running  between  the 
remains  of  the  old  acetabulum  and  the  stunted  upper 
extremity  of  the  femur.  Here,  there  is  neither  depression, 
nor  new  socket  upon  the  ilium,  and  the  numerous  auxili- 
ary ligamentous  fibres,  which  seem  to  occupy  the  place  of 
a  new  capsule,  take  their  origin  from  the  plain  surface  upon 
the  ilium,  and  run  forwards,  converging,  to  become  incor- 
porated with  the  posterior  aspect  of  the  ligamentous 
remains  of  the  ancient  capsule       Vide  Plate  ix. 

The  Synovial  Membrane  and  the  Articular  Car- 
tilage   of  the  primitive    cotyloid    cavity,   like   the   same 


160  PATHOLOGY. 

structures  covering  the  head  of  the  femur,  gradually  disap- 
pear, leaving,  in  some  instances,  the  osseous  tissue  entirely 
denuded. 

We  see  then,  from  this  account  of  the  articular  apparatus 
of  the  hip-joint,  as  it  appears  in  the  different  forms  of  conge- 
nital dislocation  of  the  femur  upon  the  ilium,  pathological 
conditions,  essentially  distinct,  which  must  exert  an  impor- 
tant bearing  upon  the  prognosis,  and  probable  efficacy  of  the 
therapeutic  means  that  may  be  adopted  in  this  affection.  In 
one  case,  the  capsule  is  found  to  retain  its  continuity  of  struc- 
ture, and  the  head  of  the  femur  rests  enclosed  in  it  on  the 
ilium,  towards  the  margin  of  the  acetabulum,  or  entirely 
upon  the  dorsum  ilii.  In  another,  the  capsule  is  found  con- 
verted into  a  conglomerated  fibrous  cord,  which  at  one  of 
its  attachments  grasps  firmly  the  upper  part  of  the  femur, 
and  is  sufficiently  extended  to  allow  the  head  of  this  bone 
to  play  upon  the  dorsum  ilii  through  a  space  of  from  one 
to  three  inches.  (  Vide  Plates  viii.  and  ix.)  In  this  case  the 
head  of  the  femur  has  disappeared,  but  in  neither  of  these 
two  cases  does  nature  attempt  to  produce  a  new  osseous 
socket  upon  the  external  surface  of  the  ilium,  although  a 
simple  depression  may  sometimes  be  found. 

In  a  third  condition  of  the  pelvis,  the  round  ligament 
has  most  frequently  disappeared,  and  the  head  of  the 
femur  is  found  in  direct  contact  with  the  external  surface 
of  the  ilium,  having  passed  through  a  perforation  in  the 
upper  portion  of  the  articular  capsule.     (Vide  Plates  vi. 


PATHOLOGY.  16] 

aud  vii.)  In  cases  of  this  kind,  an  effasion  of  new  osseous 
matter,  more  or  less  profuse,  in  the  shape  of  a  socket,  is 
often  found  upon  the  dorsum  of  the  ilium.  This  effort 
of  nature  is  similar  to  the  process  which  occurs  in  those 
instances  of  traumatic  dislocations  that  have  been  allowed 
to  remain  unreduced.  At  times,  however,  notwithstand- 
ing the  assertion  of  M.  Guerin  to  the  contrary,  a  simple 
depression  only  exists  upon  the  dorsum  ilii,  although  the 
capsule  has  become  perforated  and  the  head  of  the  femur 
lies  in  direct  contact  with  the  dorsum  of  the  ilium. 
( Vide  Plate  vii.)  In  the  two  first  conditions  of  the 
parts,  no  new  articulation  is  ever  formed,  but  in  the  third, 
a  new  socket  may  be  produced,  as  well  as  a  new  capsule, 
and  a  kind  of  pseudo-articulation  thus  result. 

The  Muscles. — The  pathological  state  of  muscular 
retraction,  by  the  instrumentality  of  which  the  dislocation 
of  the  head  of  the  femur  is  primarily  produced,  has 
already  been  considered,  under  the  head  of  etiology. 
The  muscles  surrounding  the  hip  suffer  a  still  farther 
shortening,  owing  to  the  contraction  resulting  from  the 
unnatural  position  in  which  they  are  placed  when  the 
dislocation  has  actually  occurred  The  points  of  origin 
and  of  insertion  ot  several  of  the  muscles  now  become 
approximated,  and  this  circumstance  is  another  cause 
which  tends  still   farther  to  produce  a  shortened    state  of 


162  PATHOLOGY. 

the  muscles  originally  implicated  in  the  production  of  the 
dislocation.  The  existence  of  the  abnormal  retraction  of 
the  muscles  is  necessarily  one  of  the  chief  obstacles  to 
the  permanent  success  of  the  reduction  of  the  head  of  the 
femur  to  its  natural  position. 

At  the  same  time  that  the  points  of  origin  and  of  in- 
sertion of  the  pelvi-femoral  muscles  are  relatively  changed, 
the  course  of  their  fibres  assumes  a  different  direction 
from  that  which  is  natural  to  them  while  the  normal  dis- 
position of  the  component  parts  of  the  joint  is  main- 
tained. 

In  progress  of  time,  the  muscular  tissue  itself  becomes 
changed.  It  may  present  a  fibrous  appearance,  or  it  may 
be  pervaded  by  a  fatty  degeneration,  and  become  atro- 
phied ;  or  in  some  cases  it  may  even  become  hypertro- 
phied.  These  conditions  of  the  muscular  tissue  result 
from  the  perverted  action  of  the  pelvi-femoral  muscles, 
some  of  them  being  so  placed  as  seldom  to  be  brought 
into  a  state  of  action,  while  additional  exertion  is  required 
of  others.  The  increased  exercise  which  certain  muscles 
have  to  undergo,  induces  a  hypertrophic  state,  as  often 
happens  in  some  portions  of  the  gluteus  maximus,  gracilis, 
&c,  while,  where  the  traction  is  still  more  energetic  and 
continued,  fibrous  degeneration  takes  place,  as  is  seen  in 
the  conjoined  tendons  of  the  psoas-magnus  and  iliacus 
internus,   and  frequently  of  the  gluteus  minimus;  while 


PATHOLOGY,  ]G3 

fatty  degeneration  and  atrophy  arc  the  conseqaence  of 

the  relaxation  and  inertia  which  follow  the  approxima- 
tion of  the  points  of  origin  and  insertion  of  some  of 
the  muscles,  examples  of  which  are  met  with  in  most 
of  the  pelvi-trochanteric  muscles;  such  as  the  gluteus 
medius,  &c. 

From  what  has  been  said  in  relation  to  the  mor- 
bid retraction  of  the  muscles,  and  the  fibrous  transforma- 
tion which  pervades  the  tissue  of  some  of  them,  it 
would  seem  that  these  conditions  in  themselves  must 
sometimes  form  an  insurmountable  obstacle  to  the  perma- 
nent reduction  of  the  head  of  the  femur.  Upon  this  con- 
sideration, the  principle  of  dividing  the  implicated  muscles 
by  subcutaneous  section,  as  in  the  treatment  of  Talipes, 
and  some  other  articular  deformities,  has  been  applied  to 
the  retracted  muscles  of  the  hip-joint,  in  cases  of  conge- 
nital dislocation  of  the  head  of  the  femur.  This  exten- 
sion of  myotomy  was  suggested  by  M.  Guerin,  and  merits 
attention,  as  one  of  the  resources  that  may  be  made  avail- 
able in  cases  of  this  displacement. 

Arteries  and  Veins. — The  arteries  in  persons  affected 
with  congenital  dislocation  of  the  femur  do  not  take  the 
direct  course  which  is  observed  in  their  normal  distribu- 
tion. They  are  hV\uoiis  and  serpentine,  and  exhibit  a  con- 
tracted state  of  their  calibre,  while  the  reins  are  direct  to 
their   course,  and    larger  in    diameter  than    in   the  natural 


164  PATHOLOGY. 

condition  of  the  parts.  The  arteries  of  the  ligamentum 
teres  must,  in  the  early  period  of  the  displacement,  become 
compressed,  and  finally,  when  this  ligament  becomes  rup- 
tured, or  has  given  way  from  pressure,  and  disappeared, 
the  head  of  the  femur  must  be  deprived  of  the  nutrition 
supplied  to  it  through  the  medium  of  this  structure. 

Nerves. — The  nerves,  which  are  generally  found  to  be 
smaller,  are  disposed  in  such  a  manner  as  to  take  a  direct 
course  to  arrive  at  their  distribution  in  the  muscular 
tissue.  Therefore  they  might,  from  the  shortening 
resulting  from  this  arrangement,  be  the  source  of  consi- 
derable pain  during  the  efforts  made  in  attempting  to 
accomplish  the  reduction  of  the  luxation.  The  arteries 
in  this  respect  are  differently  disposed;  for  being  flexuous, 
the  extension,  by  which  the  extremity  can  be  elongated, 
would  only  efface  their  sinuosities  without  putting  these 
vessels  on  the  stretch. 

Cellular  Tissue  and  Skin. — The  cellular  tissue  is 
generally  abundant,  is  studded  with  pelotons  of  adipose 
tissue,  and  pervades  in  considerable  quantity  the  depres- 
sions resulting  from  the  new  disposition  of  the  parts,  as 
well  as  the  inter-muscular  spaces.  The  skin,  in  old  sub- 
jects, is  apt  to  be  flaccid,  but  presents  nothing  unnatural, 
except  the  ordinary  appearances  which  might  be  expected 
to   result    from  enfeebled    nutrition.      The   facility   with 


PATHOLOGY,  166 

which  the  cutaneous  and  cellular  structures  will  accom- 
modate themselves  by  their  elasticity  to  extension  exerted 
upon  the  limb,  would  prevenl  their  ever  offering  anj  obsta- 
cle in  attempts  to  effect  the  reduction  of  the  head  of  the 

femur  to  its  natural  position. 

Changes  which  take  place  in  the  Osseous  Tissue. 
— The  alterations  which  occur  in  the  parts  of  the  skele- 
ton in  proximity  to  the  morhid  articulation,  or  even  at  a 
considerable  distance  from  it,  merit  consideration.  From 
the  perverted  and  diminished  nutrition  to  which  the  osse- 
ous tissue  is  subjected  in  this  malady,  alterations  occur  in 
the  different  portions  of  the  pelvis,  extending  to  the 
femur,  and  to  the  other  component  parts  of  the  bony 
structure  of  the  inferior  members,  producing  ultimately 
formidable  complications  during  the  progress  of  this  affec- 
tion. 

As  far  as  my  own  observations  extend,  the  diameters 
and  the  several  measurements  of  the  pelvis  are  invariably 
changed,  and  the  tissue  of  the  bones,  not  only  of  the  ossa 
femora,  but  also  of  those  more  remote,  undergo  alterations 
in  their  texture,  density,  and  volume.  The  thigh  bones 
and  the  tibia  and  fibula,  as  is  seen  in  the  drawing  of  one 
ot  the  cases  I  examined  (vide  Plates  viii.  and  ix.),  have 
participated  very  materially  in  the  degeneration  of  struc- 
ture. 

This  softened  and  fragile  condition  of  the  I. ones  is  dil- 


166  PATHOLOGY. 

ferent  from  that  which  has  received  the  name  of  rachitis. 
In  the  osseous  deterioration  of  the  pelvis  and  femurs,  in 
persons  laboring  under  congenital  dislocation  of  the  hip- 
joint,  there  is  no  reparatory  attempt  made  towards  the 
restoration  of  the  osseous  structure  while  the  displace- 
ment exists.  In  rachitis,  however,  the  soft  and  yielding 
state  of  the  bones  is  generally  temporary,  and  in  fact  the 
rachitic  bone,  once  cured,  often  presents  a  denser  and  more 
compact  interior  texture,  than  a  bone  which  had  never 
suffered  from  this  disease,  as  may  be  observed  on  the  con- 
cavity of  the  long  bones  which  have  suffered  from  rachitic 
derangement. 

The  osseous  structure  depends  indirectly  upon  the  vas- 
cular supply  to  the  periosteum,  and  to  the  internal  medul- 
lary membrane,  for  its  healthy  nutrition.  As  has  already 
been  observed,  the  arteries  in  the  vicinity  of  the  disloca- 
tion are  not  in  their  normal  condition,  besides  being 
under  their  usual  size.  As  a  natural  consequence  of  this, 
the  medullary  membrane  is  not  supplied  sufficiently  for 
the  interior  nutrition  of  the  bone,  while  from  the  same 
inadequate  supply  to  the  periosteum,  the  more  superficial 
parts  likewise  suffer  in  this  respect.  When  this  is  taken 
into  consideration,  it  may  reasonably  be  expected  that  the 
pelvis  and  femurs  would  become  deteriorated  in  their  tex- 
ture. 

In   connexion    with   the  increased   muscular   traction 
which,  in  congenital   luxation,  must  take   place  during 


PATHOLOGY.  1G7 

locomotion,  this  deficiency  of  density  and  the  fragile  state  of 
the  hones  predispose  to  the  production  of  osseous  malfor- 
mations, and  thus  the  curvatures,  and  fractures  even,  of 
the  long  bones,  such  as  the  femur,  can  be   satisfactorily 

accounted  for.      Vide  Plates  viii.  and  ix. 

Changes  Observed  in  the  Configuration  of  the 
Skeleton  of  the  Pelvis,  &c. — The  pelvic  diameters 
and  other  measurements  are  materially  changed  in  cases 
of  long  standing,  the  alterations  being  modified,  according 
as  the  dislocation  is  present  upon  one  side  only,  or  simul- 
taneously upon  both.  The  assertion  of  Dupuytren,  in 
regard  to  the  natural  conformation  of  the  pelvis  being 
maintained  in  cases  of  either  single  or  double  congenital 
dislocation  of  the  femur  on  the  ilium,  is  proved  now  by 
pathological  investigations,  to  be  incorrect.  In  the  speci- 
mens which  I  have  had  the  opportunity  of  examining 
and  of  dissecting,  the  diameters  of  the  pelves  were  mate- 
rially changed  from  the  normal  standard,  and  I  have  no 
doubt  that  similar  irregularities  will  be  observed  to  exist, 
as  a  general  rule. 

During  life,  and  in  the  erect  posture,  where  there  is 
dislocation  upon  one  side  only,  the  hip  posteriorly,  of  the 
side  affected,  is  apparently  more  elevated,  owing  to  the 
projection  of  the  trochanter  major;  but  the  ilium  is  found 
to  have  descended  lower  than  the  corresponding  part  of 
the  opposite  side.      In    the  skeleton,   however,   the  half 


168  PATHOLOGY. 

of  the  pelvis,  which  corresponds  to  the  dislocation,  is 
dragged  or  twisted  from  before  backwards,  and  from  below 
upwards,  so  that  the  side  of  the  pelvis  upon  which  the 
dislocation  has  existed,  is  situated,  in  relation  to  the  os 
innominatum  of  the  sound  side,  upon  a  higher  plane 
and  more  posterior,  than  on  the  side  where  the  head  of 
the  femur  has  maintained  its  normal  position. 

At  the  superior  strait,  the  antero-posterior  diameter  of 
the  affected  half  is  diminished,  and  the  symphysis  pubis 
is  drawn  beyond  the  mesial  line,  in  the  direction  of  the 
affected  side.  The  semi-inferior  strait  corresponding  to 
the  affected  side,  on  the  contrary,  appears  more  open 
and  enlarged  laterally,  and  is  drawn,  as  it  were, 
outwards  and  upwards.  These  malformations,  occur- 
ring in  the  diameters  of  the  straits,  although  confined 
chiefly  to  one  side,  necessarily  interfere  with  the  functions 
of  parturition,  and  render  it  difficult  and  dangerous  ;  and 
after  reduction,  where  this  is  practicable,  they  would  still 
be  a  source  of  lameness. 

The  individual  parts  of  the  pelvis  on  the  affected  side, 
present  also  deviations  from  the  natural  configuration. 
The  ilium,  besides  being  more  thin  and  atrophied, 
is  more  vertical  and  less  excavated.  The  anterior 
superior  spinous  process  of  the  ilium  is  carried  some- 
what inwards ;  the  inferior  anterior  iliac  spine  is 
more  prominent  than  natural,  and  immediately  below 
it,    and    between    it    and    the    eminentia    ilio-pectinea, 


PATHOLOGY.  I G9 

is  observed  a  deep  groove,  in  which  the  conjoined 
tendon  of  the  iliacus  interims  and  psoas  magnns  has 
played.  (Vide  Plate  viii.)  The  transverse  or  horizon- 
tal branch  of  the  pubes  is  longer  and  more  slender,  and  is 
directed  more  obliquely  upwards  and  backwards,  than  the 
corresponding  part  of  the  sound  side 

The  ischium  is  drawn  outwards  by  the  pelvi-trochan- 
teric  muscles,  so  that  the  tuberosity  is  seen  situated  more 
externally  than  on  the  opposite  side.  As  a  consequence 
of  the  change  of  direction  outwards  of  the  ischium  and 
of  the  descending  ramus  of  the  pubes,  the  long  diameter 
of  the  obturator  foramen  is  found  to  be  disposed  nearly 
transversely,  instead  of  almost  vertically. 

When  the  head  of  the  femur  is  dislocated  upon  the  ilium 
on  both  sides,  both  halves  of  the  osseous  pelvis  participate 
in  the  deformity,  and  frequently  the  alterations  are  so 
nearly  alike  on  either  side,  that  the  resulting  malforma- 
tions are  symmetrical. 

The  wings  of  the  ossa  innominata  in  this  case,  are 
found  less  dense,  smaller,  and  more  vertical ;  the  anterior 
inferior  spinous  processes  of  the  ilia  are  found  prominent, 
and  the  depressions  existing  below  them  are  seen  to  be 
deeply  grooved  by  the  continued  traction  of  the  tendons, 
which  played  in  them  during  life.  (Vide  Plates  vi.  and 
viii.)  The  horizontal  rami  of  the  pubes  are  found  also 
more  slender  and  longer,  extending  considerably  farther 
outwards,  on  each  side  from  the  symphysis,  than  in  the 

12 


170  PATHOLOGY. 

natural  state  ;  while  the  body  of  the  pubes,  on  each  side 
of  the  symphysis,  is  less  deep,  and  also  more  fragile  in  tex- 
ture. The  ischia  are  drawn  outwards,  and  the  long  diame- 
ters of  the  foramina  obturatoria  run  somewhat  in  a  transverse 
direction,  instead  of  being  nearly  vertical.  The  sacrum 
is  generally  more  stunted,  and  narrower  than  natural.  Vide 
Plates  vi.  and  vn. 

The  superior  strait  of  the  pelvis  is  contracted  in  the 
antero-posterior  diameter,  while  laterally  or  transversely 
the  measurement  is  proportionally  increased,  although,  as 
the  whole  pelvis  is  generally  on  a  smaller  scale,  this  mea- 
surement is,  in  reality,  less  than  is  met  with  in  a  well 
formed  pelvis. 

The  inferior  strait  presents  a  contraction  in  the  mea- 
surement from  the  apex  of  the  coccyx  to  the  arch  of  the 
pubes,  while  the  transverse  diameter  between  the  ischia, 
is  considerably  more  ample  than  in  the  natural  pelvis. 
Vide  Plates  vi.  and  vn. 

From  this  statement,  it  is  evident  that  so  great  a  de- 
parture from  the  normal  relations  of  the  different  measure- 
ments and  straits  of  the  pelvis,  must  of  themselves  add  to  the 
lameness,  as  well  as  materially  impede  the  progress  of  the 
head  of  the  full  grown  fcetus,  in  its  passage  through  the 
pelvis,  during  parturition,  and  that  a  difficulty  may  be 
anticipated  so  formidably,  as  to  render  the  intervention  of 
instrumental  aid  necessary  to  preserve  the  life  of  the 
mother.     From   the  extent  of  malformation  which  takes 


PATHOLOOT.  171 

place  in  the  pelvis,  whether  the  dislocation  be  single  01 
double,  there  seems  little  reason  to  suppose  that  in  either 

case  the  obstacles  to  parturition  would  be  materially  lessened. 

Analysis  of  the  Malformations  op  the  Pelvis. — 
The  extent  of  the  deformity  which  pervades  the  pelves 
of  individuals  who  are  affected  with  congenital  disloca- 
tion upon  the  dorsum  ilii,  must  in  a  great  degree  be  sub- 
ordinate to  the  extent  of  the  displacement  of  the  head  of  the 
femur,  and  also  to  the  length  of  time  the  luxation  may  have 
existed.  The  characteristics,  however,  of  these  malfor- 
mations are  generally  so  similar  and  definitely  marked, 
that  they  can  be  chiefly  referred  to  a  set  of  anatomical 
causes  which  must  always  exert  their  influence  during 
the  existence  and  progress  of  this  affection. 

The  escape  of  the  head  of  the  femur  from  the  confines 
of  the  acetabulum,  and  its  ascent  upon  the  dorsum  ilii, 
will  necessarily  change  the  direction  and  relative  action 
of  all  the  muscles  inserted  into  the  upper  portion  of  the 
femur.  The  psoas  magnus  and  iliacus  interims,  on  each 
side,  when  the  luxation  is  double,  will  be  put  upon  the 
stretch  in  proportion  as  their  points  of  insertion  at  the 
trochanter  minor  are  dragged  upward*  during  the  ascent  of 
the  head  of  the  femur. 

The  quadratus  femoris,  the  gcmelli,  the  obturatorcs,  the 
pectineus,  and  probably  tin1  upper  portion  of  (be  adductor 
magnus,  attached  on   the   one   side  to  the  pelvis,  and  on 


172  PATHOLOGY. 

the  other  to  the  upper  portion  of  the  femur,  are  also  put 
upon  the  stretch  by  the  removal  of  their  points  of  inser- 
tion at  the  femur  to  a  greater  distance  from  their  points  of 
origin.      Vide  Plate  hi. 

In  connexion  with  the  deteriorated  organization  of  the 
bones  of  which  the  pelvis  is  constructed,  the  increased 
traction  exercised  by  the  muscles,  and  the  perverted 
direction  in  which  they  must  now  act,  during  progression, 
will,  to  a  certain  extent,  account  for  many  of  the  changes 
which  are  observed  in  the  form  and  dimensions  of  the 
pelvis.  The  vertical  direction  which  the  wings  of  the 
ilia  acquire,  may  result  from  the  suspended  antagonism 
between  the  iliacus  internus  on  the  one  hand,  and 
the  gluteus  medius  and  gluteus  minimus  on  the  other. 
The  ascent  of  the  femur  puts  these  two  glutei  into  a 
state  of  relaxation  and  consequent  inactivity,  as  regards 
their  effect  upon  the  dorsum  ilii ;  while,  on  the  contrary, 
the  iliacus  internus  is  in  a  state  of  tension,  which  tends  to 
pull  inwards  the  internal  iliac  fossa.  The  deep  groove  to 
be  seen  below  the  anterior  and  inferior  spinous  process 
of  the  ilium  is  evidently  the  result  of  the  tractions  exer- 
cised upon  the  conjoined  tendons  of  the  psoas  magnus 
and  iliacus  internus  muscles,  which  pass  over  this  groove 
like  the  cord  of  a  pulley,  and  play  in  it  during  progression. 
These  tendons,  by  their  continued  traction  on  each  side, 
will  tend,  besides,  to  elongate  outwardly  the  horizontal 
ramus  of  the  pubes.     The  ischia  are  pulled  outwards  by 


PATHOLOGY.  173 

the  continued  traction  of  the  quadratus  femoris,  the  superior 
.ukI  interior  gemelli,  and  the  obturator  internus,  while  the 

obturator  externus  impresses  the  mark  of  its  passage  over 
the  anterior  and  external  part  of  the  body  of  the  ischium  ; 
the  tractions  of  the  upper  fibres  of  the  adductor  magnus 
on  each  side  may  also  aid  in  separating  the  descending  rami 
of  the  pubes,  and  thus  contribute  to  enlarge  the  angle 
below   the   symphysis  pubis.      Vide  Plates   hi.,  vi.,  and 

VII. 

These  abnormal  results,  in  the  configuration  of  the 
pelvis,  brought  about  by  the  perverted  action  of  the  pclvi- 
femoral  muscles,  are  materially  augmented  by  the  influ- 
ence which  the  weight  of  the  body  exerts  upon  the  mus- 
cles, during  locomotion,  after  the  heads  of  the  ossa  femorum 
have  escaped  from  the  limits  of  the  acetabula.  It  mav 
easily  be  understood  that,  as  soon  as  the  heads  of  the 
femurs  have  mounted  on  the  ilia,  and  lost  the  fixed  sup- 
port which  they  naturally  receive  from  the  walls  of  the 
cotyloid  cavity,  the  trunk  must  sink  down,  as  it  were, 
between  the  upper  portions  of  the  ossa  femorum.  An  ad- 
ditional superincumbent  weight  being  now  thrown  in  a 
great  degree  upon  the  muscles  surrounding  the  hip-joint, 
the  traction  exercised  by  those  muscles  which  are 
attached  to  the  framework  of  the  pelvis,  is  necessarily 
increased,  and  the  fragile  osseous  tissue  becomes  distorted 
in  the  direction  of  the  action  of  theil  fibres. 

It   is   also    by    the   agency   of  the  several  causes  above 


174  PATHOLOGY. 

mentioned,  confined,  however,  to  one  side  only,  that  the 
lateral  parts  of  the  pelvis  corresponding  to  the  side 
affected,  become  deformed  and  drawn  upwards  and  back- 
wards, in  cases  of  single  congenital  luxation  of  the  femur 
upon  the  ilium. 

The  occurrence  of  fracture  of  the  femurs,  as  well  as  of 
the  bending  of  these  bones,  and  of  the  tibia  and  fibula, 
which  is  sometimes  observed,  must  also  be  attributed  to 
the  deteriorated  condition  of  the  bones  themselves,  and  to 
the  increased  action  imposed  upon  the  muscles,  both  by 
the  superincumbent  weight  of  the  body,  and  by  the  ordi- 
nary muscular  contractions  which  come  into  play  during 
the  different  acts  of  locomotion. 

These  pathological  remarks  on  the  changes  which  take 
place  in  congenital  dislocations  of  the  femur,  at  the  ilio- 
femoral articulation,  in  the  osseous  structure  in  proximity 
to  it,  and  in  the  soft  tissues  by  which  this  joint  is  sur- 
rounded, will  be  referred  to,  when  the  subject  of  treatment 
comes  to  be  considered,  as  they  have  a  direct  bearing  upon 
the  curability  of  these  affections. 

I  shall  now  proceed  to  the  description  of  a  case  of 
double  congenital  luxation  of  the  heads  of  the  femurs 
upon  the  dorsa  of  the  ilia,  which  I  select  from  those  I  have 
had  an  opportunity  of  examining  after  death,  as  a  pure 
and  uncomplicated  specimen  of  this  affection,  and  as  signally 
elucidating  its  pathological  characters.* 

*  I  take  pleasure  iu  acknowledging  here  the  facilities  afforded  me  hi  the  prosecu- 


PATHOLOGY.  L75 

It  presented  all  the  pathognomonic  characters  exter- 
nally, appertaining  to  the  case  related  al  page  L06  el  seq., 
and  which  is  delineated  in  Plates  Nos.  i.,  il,  and  iv. 

To  aid  the  description  of  the  parts,  I  refer  to  the 
admirably  executed  drawings  of  the  pelvis  and  the  liga- 
ments of  the  coxo-femoral  articulation,  as  seen  imme- 
diately after  the  removal  of  the  soft  tissues,  in  Plates  vl 
and  vn. 

The  subject  from  which  the  following  description  is 
taken — a  female,  apparently  between  sixty  and  seventy 
years  of  age — as  observed  while  lying  on  the  table,  is  seen  to 
be  somewhat  emaciated,  but  this  condition  is  most  evident 
as  regards  the  inferior  extremities.  The  soft  parts  about 
the  basin  are  flabby  ;  a  considerable  disproportion  between 
the  size  of  the  trunk  and  the  length  of  the  inferior  ex- 
tremities is  observable,  owing  to  the  ascent  of  the  heads 
of  the  femurs  upon  the  dorsa  of  the  iliac  bones.  The 
head,  thorax,  and  abdomen,  present  nothing  abnormal 
while  the  body  is  in  a  recumbent  position,  but  being 
placed  in  the  erect  attitude,  the  superior  extremities 
appear  too  long  for  the  trunk;  the  trunk  itself  appearing 
as  it  were,  wedged  and  sunk  between  the  upper  portion 
of  the  femurs.  The  thorax  and  abdomen  an1  thrown  for- 
ward with  a  salient  anterior  curve,  while  the  region  ol  the 


don  of  my  inquiries  on  this  suhj</ct,hy  M.  I>    L<-m:ir<iuuy,  at  that  time  connected  with 
the  Hdtel  thui  ami  \\w  Emir  Pratique,  of  Pans. 


176  PATHOLOGY. 

loins,  and  the  lower  part  of  the  dorsal  vertebrae,  present  a 
curvature  forwards  with  a  corresponding  concavity.    In  this 
latter  position,  also,  the  anterior  superior  spinous  processes 
of  the  ilia  are  thrown  forwards,  while  the  lower  part  of  the 
sacrum  and  coccyx  take  a  direction   upwards  and   back- 
wards ;  the  base  of  the  sacrum  being  consequently  tilted 
forwards  and  downwards.     The  eristic  of  the  iliac  bones 
are  almost  vertical,  and  the  trochanters  can  be  felt  stand- 
ing out  at  a  right  angle  to  the  external  surface  of  the  dor- 
sum, nearly  on  a  level  with  the  posterior  portion  of  the 
crests,  and  forming  the  apex  of  a  conoid  eminence,  the 
base  of  which  is  at  the  ilium  itself.     The  heads  of  both 
femurs   enjoy  free   motion    upon  the   dorsa    of  the   iliac 
bones,  and,  while  the  trochanters  can  be  pushed  upwards 
and  outwards,  so  as  to  be  within  half  an  inch  of  the  crests 
of  the  ilia,   when  traction    in   the  opposite  direction    is 
exerted,  they  are  felt  to  descend  through  a  space  of  nearly 
two  inches,  and  become  nearly  on  a  level  with  a  direct 
line  drawn  transversely  from  the    depressed  anterior  and 
superior  spinous  processes.     The  pelvis  itself,   with  the 
exception  of  the  unusual  inclination   of  its  axes,  and  the 
unnatural  projection  caused  posteriorly  by  the  abnormal 
position  of  the  trochanters,  appears  to  be,  in  other  respects, 
tolerably    well   formed;    the    transverse    diameter   being, 
however,    somewhat    increased    at   the    expense    of  the 
antero -posterior,  but  neither  as  regards  the  pelvis,  nor  the 
other  osseous  parts  of  the  extremities  or  trunk,  are  there 


PATHOLOGY.  177 

to  be  seen  ;m\  evidences  of  a  rachitic  disposition.  Between 
the  anterior  and  superior  spinous  processes,  there  isa  distance 
of  eight  inches;  between  the  anterior  superior  spinous  pro- 
cess and  the  tuberosity  of  tin*  pubes,  lour  inches  and  a 
half;  while  between  the  tuberosities  of  the  ischia  there  is 
a  space  of  five  inches  and  three  quarters,  showing  a  con- 
siderably exaggerated  diameter  in  this  direction.  The 
nearly  equilateral  triangle  observed  in  the  natural  position  of 
the  parts,  between  the  upper  margin  of  the  trochanter,  the 
tuberosity  of  the  pubes,  and  the  anterior  superior  spinous 
process  of  the  ilium,  is  altogether  changed,  the  measure- 
ments between  these  several  points  differing  materially, 
according  as  the  head  of  the  femur  is  pushed  upwards,  or 
is  drawn  downwards  upon  the  dorsum  of  the  ilium.  The 
play  of  motion  which  the  head  of  the  femur  must  have 
had  in  the  act  of  progression  during  life,  may  be  said  to 
have  been  about  two  inches,  as  that  extent  of  change  of 
position  of  the  head  of  the  bone  can  be  obtained.  h\  an 
alternating  force  applied  to  its  shaft,  of  traction  down- 
wards, or  propulsion  upwards.  In  the  attempt  to  rotate 
or  move  in  different  directions,  the  inferior  extremity,  a 
sensation  of  crepitus  is  felt,  analogous  to  that  produced 
by  effusion  or  thickening  of  the  ligamentous  structure 
about  an  articulation  ;  and  the  various  motions  can  be 
effected  with  less  facility  than  is  generalh  observed  in  a 
healthy  joint.  Adduction  and  the  action  of  flexing  tin- 
thigh    upon    the   pelvis,    is  less   impeded     than    the  other 


178  PATHOLOGY. 

motions,  but  abduction  and  extension  are  permitted  to  a 
very  limited  extent. 

As  far  as  can  be  seen  externally,  the  dislocation  on 
both  sides  is  exactly  similar  in  every  particular,  and  the 
two  sides  of  the  pelvis,  in  regard  to  the  relations  they 
bear  with  the  displaced  head  and  trochanter  of  the  femur, 
offer  no  perceptible  variety.  It  will  be  seen  by  reference 
to  the  case  already  inserted,  at  page  106  et  seq.,  that  the 
pathognomonic  characters  described,  as  belonging  to  the 
patient  there  alluded  to,  are  perfectly  analogous  to  those 
which  claim  our  consideration  in  the  present  instance. 

The  external  appearances  then  being,  in  both  cases,  the 
one  a  facsimile  of  the  other,  it  may  reasonably  be  sup- 
posed that  the  deeper  tissues  are  also  analogous.  After 
these  preliminary  remarks,  as  regards  the  external  charac- 
ters or  signs  presented  by  the  double  congenital  luxation 
of  the  head  of  the  femur  upon  the  dorsum  ilii,  we  shall 
now  describe  the  appearances  met  with  upon  dissection ; 
first  of  the  soft  parts,  and  then  in  connexion  with  the 
articular  surfaces  appertaining  to  the  skeleton. 

The  skin  occupying  the  region  of  the  haunch  is  soft 
and  flaccid,  but  in  other  respects  presents  nothing  remark- 
able. The  subcutaneous  adipo-cellular  layer  is  dense 
and  interspersed  with  pelotons  of  adipose  tissue,  which 
also  are  more  condensed  than  usual.  The  aponeurosis 
covering  the  glutei  is  natural,  but  in  attempting  to  remove 
this  from  the  gluteus  maximus,  the  fibres  of  this  muscle 


PATHOLOGY.  L79 

are  found  to  be  so  friable,  that  it  is  impossible  to  remoi  e  the 
investing  fascia,  without  carrying  along  with  it  some  of  the 
degenerated  muscular  tissue.     The  first  layer  of  muscles 

O  J 

being  exposed,  consisting  of  the  gluteus  maxinius,  the 
anterior  portion  of  the  gluteus  medius,  and  the  upper  por- 
tion of  the  semi-membranosns,  semi-tendinosus,  and 
biceps,  the  general  character  of  the  muscular  tissue  is 
found  to  be  much  changed.  These  muscles  are  soft, 
flabby,  and  pale,  and  have  undergone,  in  many  points,  a 
partial  conversion  from  the  muscular  into  a  kind  of  yel- 
lowish, fatty  tissue.  This  is  particularly  to  be  observed 
with  regard  to  the  gluteus  maxinius  and  the  anterior  por- 
tion of  the  gluteus  medius,  but  the  other  muscles  partici- 
pate more  or  less  in  the  degeneration.  The  muscular 
fibres,  in  regard  to  their  length,  seem  to  have  accommo- 
dated themselves  to  their  altered  position,  and  are 
found  to  be  shorter  than  they  ought  to  be,  when  the  nor- 
mal relation  of  the  parts  exists,  and  this  can  easily  be 
understood  when  it  is  considered  that  the  points  of  origin 
and  insertion  are  considerably  approximated  by  the  ascent 
of  the  head  of  the  femur.  The  gluteus  maximus  being 
divided  transversely  through  its  middle,  and  the  two  por- 
tions reflected,  an  unusual  quantity  of  adipo-cellular tissue 
is  met  with  enveloping  the  large  nerves,  arteries,  and 
veins  situated  beneath  this  muscle.  Bj  removing  this 
loose  tissue,  the  deep-seated  muscles  are  exposed,  and  are 
found  to  have  undergone  the  same  fattj  degeneration  as 


180  PATHOLOGY. 

the  more  superficial  layer,  and  the  change  or  alteration  in 
the  direction  of  their  fibres  is  particularly  evident.  Thus 
the  quadratus  femoris,  obturator  externus,  gemelli,  and 
obturator  internus,  instead  of  passing  transversely  outwards, 
as  they  generally  do,  assume  a  direction  almost  directly 
upwards,  and  but  slightly  outwards,  to  arrive  at  their 
point  of  insertion,  at  the  root  of  the  great  trochanter. 
The  pyriformis,  which  in  the  healthy  subject  is  inclined 
downwards  from  its  origin,  has  taken  an  inverse  direction, 
and  ascends  upwards  and  outwards  to  reach  its  place  of 
insertion  at  the  digital  fossa.  In  regarding  the  parts  from 
above  downwards,  the  gluteus  medius,  pyriformis,  and 
obturator  internus,  instead  of  resting  upon  the  posterior 
portion  of  the  cotyloid  cavity,  lie  upon  the  partially 
destroyed  head  of  the  femur  and  the  posterior  surface  of 
the  coxo-femoral  capsule.  The  gluteus  medius,  the  an- 
terior fibres  of  which  have  become  transverse,  is  pushed 
upwards  towards  the  iliac  crest,  while  the  gluteus  mini- 
mus is  also  shortened,  and  more  fibrous  than  natural,  par- 
ticularly towards  its  insertion,  where  it  becomes  con- 
founded with  the  capsular  ligament. 

Upon  removing  the  tegumentary  tissues  from  the  ante- 
rior and  upper  part  of  the  thigh,  the  femoro-pelvic  muscles 
in  that  region  are  found  to  be  shorter  than  natural,  by  the 
amount  of  the  distance  that  the  head  of  the  femur  has 
passed  up  beyond  the  cotyloid  cavity.  The  same  fatty 
degeneration    and    paleness    of    muscular   tissue    before 


PATHOLOG1 .  1  v  I 

alluded  to,  is  found  to  pervade,  more  or  less,  the  rectos, 
tensor  vaginae  femoris,  and  the  belly  of  the  Iliacus  Inter- 
ntis.  The  sartorius  and  adductors  presenl  a  more  normal 
appearance  of  tissue,  as  docs  also  the  gracilis,  which  last 
is  even  somewhat  hypertrophied.  The  psoas  magnus, 
taking  its  usual  origin  from  the  bodies  and  transverse 
processes  of  the  last  dorsal  and  lumbar  vertebra-,  passes 
downwards,  and  becomes  tendinous  about  its  middle. 
Where  it  passes  over  the  brim  of  the  pelvis  and  becomes 
mixed  with  the  iliacus  interims,  a  strong  cord-like  tendon 
results  from  the  junction  of  these  two  muscles,  which, 
instead  of  passing  downwards  and  outwards  to  the  usual 
point  of  insertion,  hooks,  as  it  were,  over  the  margin  of 
the  pelvis,  below  the  anterior  inferior  spinous  process  of 
the  ilium,  where  it  forms  a  deep  groove ;  it  then  takes  a 
course  upwards,  outwards,  and  slightly  backwards,  to  the 
extent  of  nearly  three  inches,  to  gain  the  trochanter 
minor.  It  is  important  to  bear  iti  mind  the  reflected 
course  of  the  tendon  of  the  psoas  magnns,  as  it  accounts 
anatomically  for  the  curvature  forwards  of  the  lumbar 
region,  and  also  operates  in  conjunction  with  the  short- 
ened state  of  the  adductors  in  materially  impeding  the 
adduction  of  the  limb.  From  the  continued  friction  to 
which  the  parts  must  have  been  subjected  during  life  in 
the  act  of  locomotion,  a  large  bursa,  extending  in  various 
directions,  exists  beneath  the  conjoined  tendons  ol  the 
psoas  and  iliacus,   and  the   finger,  when  inserted  into  it, 


182  PATHOLOGY. 

meets  with  an  extensive  cavity,  which  in  the  natural  state 
would  have  been  occupied  by  the  margin  of  the  aceta- 
bulum and  a  portion  of  the  head  and  neck  of  the 
femur,  covered  with  the  anterior  part  of  the  capsular  liga- 
ment. 

The  arteries  are  much  smaller  than  natural,  and  pre- 
sent a  remarkably  tortuous  disposition,  not  unlike  the 
flexuosities  of  the  vessels  of  the  impregnated  uterus. 
Thus  the  main  arterial  trunk  of  the  pelvis  and  inferior 
extremity,  from  the  bifurcation  of  the  aorta  into  the  pri- 
mitive iliacs  to  the  place  where  the  femoral  artery  per- 
forates the  tendinous  sheath  of  the  adductor  magnus, 
presents  a  series  of  sinuosities  bending  in  various  direc- 
tions ;  and  this  disposition  is  observed  in  the  smaller 
branches,  as  well  as  in  those  which  spring  from  the 
internal  iliacs  to  supply  the  parts  on  the  gluteal 
region. 

The  veins  corresponding  to  the  arteries,  if  any  dif- 
ference exist,  are  larger  than  usual,  and  differ  from  the 
arteries  in  following  a  direct  course,  without  presenting 
any  irregular  flexuosities. 

The  nervous  centres  in  their  structure  present  nothing 
abnormal  in  their  individual  parts,  but  they  are  somewhat 
under  the  average  size.  The  remains  of  a  small  bloody 
effusion  (foyer  sanguine)  exists  in  the  substance  of  the 
corpus  striatum  of  the  left  side,  and  also  another  in  the 
cerebellum  near  the  corpus  dentatum.     The  spinal  mar- 


PATHOLOGT.  183 

row,  except  the  diminution  in  volume  just  alluded  to, 
appears  generally  natural,  and  the  nerves  forming  the 
Cauda  equina,  as  also  the  sacral  plexus,  and  the  branches 
which  take  their  origin  from  them,  viz.  obturatrix,  glu- 
teals, less  and  greater  sciatics,  &c.,  are  below  the  normal 
size. 

The  ligamentous  structure  of  the  coxo-femoral  articu- 
lation presents  peculiarities  and  changes  even  more  remark- 
able than  the  other  tissues  already  spoken  of,  and  merits 
special  attention  as  regards  the  possibility  of  effecting  the 
reduction  of  this  dislocation  after  a  certain  age,  and  the 
probability  of  maintaining  the  displaced  articular  surfaces 
in  contact,  should  the  attempt  to  reduce  the  dislocation 
be  successful.  The  form  and  dimension  of  the  capsular 
ligament  have  undergone  a  complete  change,  and  in  fact 
the  disposition  of  the  ancient  capsule,  and  the  parts  it 
originally  contained,  have  assumed  altogether  a  new 
character,  and  abnormal  relations  with  each  other.  The 
former  ligamentous  tissue  itself  has  in  some  parts  been 
replaced  by  a  fatty  structure,  and  has  become  thickened, 
or  more  attenuated  in  others. 

It  is  not  easy  to  describe  by  words  the  complex 
changes  which  the  articular  apparatus  of  the  joint  has 
undergone,  but  by  a  reference  to  the  drawings  on  Plates 
vi.  and  vii.,  the  description  of  the  parts,  as  disclosed  1>\ 
dissection,  will  he  better  understood.  Upon  each  side, 
the  coxo-femoral  articulation  has  become,  as  it  were,  fur- 


184  PATHOLOGY. 

nished  with  two  capsular  ligaments ;  one,  which  is  the 
remains  of  the  ancient  capsule,  and  the  other,  which  is  of 
more  recent  formation,  and  in  which  the  head  of  the 
femur  has  been  lodged  since  its  escape  from  the  original 
capsule.  The  old  capsule,  retaining  its  attachments  at 
the  margin  of  the  acetabulum,  has  changed  its  usual 
direction,  and  is  stretched  upwards  and  outwards,  in  pro- 
portion as  the  head  of  the  femur  has  mounted  upon  the 
dorsum  ilii.  The  head  of  the  bone  becoming  indepen- 
dent of  the  acetabulum,  and  placed  during  the  erect  pos- 
ture of  the  subject  at  the  upper  portion  of  the  interior 
of  the  natural  capsule,  would  naturally  ascend  and 
descend,  during  the  act  of  locomotion,  and  remain 
within  the  original  capsule  until,  in  the  progress  of  time, 
farther  changes  occur.  Owing  to  the  weight  of  the  body 
being  now  thrown  chiefly  on  the  capsular  ligament,  and 
the  consequent  pressure  of  the  head  of  the  femur  against 
its  upper  portion,  particularly  during  progression,  it  is 
reasonable  to  suppose  that  this  part  more  especially  of 
the  capsular  ligament,  would  be  subjected  to  material 
changes.  Tins  apparently  has  been  the  case.  The 
head  of  the  femur  acting  from  below  upon  the  superior 
and  inner  portion  of  the  old  capsule,  while  the  weight  of 
the  body  afforded  the  counter  resistance  from  above,  this 
portion  of  the  capsule,  thus  situated  between  the  internal 
part  of  the  head  of  the  os  femoris  and  the  dorsum  of  the 
ilium,  being  continually  subjected   during  the  actions  of 


PATHOLOGY.  185 

locomotion  to  the  influences  of  powerful  traction  and 
pressure  between   two  bard  bodies,  gives  way,  either  bj 

rapture,  or  more  probablj  has  become,  as  ii  were,  worn 
through  (use)  by  a  species  of  progressive  absorption. 
The  perforation  of  the  capsule  being  now  accomplished, 

and  the  weight  of  the  body  still  continuing  to  be  thrown 
upon  the  inferior  extremities,  the  bead  of  the  os  femoris, 
pressing  in  one  direction  and  the  superincumbent  weight 
of  the  body  in  another,  escapes  at  length  through  this 
perforation,  and  now  becomes  situated  upon  the  dorsum 
of  the  ilium,  in  contact,  superiorly  and  externally,  with 
the  deep  surface  of  the  gluteus  minimus,  and  inferiorly 
with  the  upper  surface  of  the  old  capsule,  an  annular 
portion  of  which  passes  around  and  thus  encircles  the 
cervix  femoris.      Vide  Plates  vi.  and  vn. 

As  happens  in  traumatic  dislocations,  the  formation  of 
a  new  capsule  has  followed  the  escape  of  the  head  of  the 
femur  from  the  confines  of  its  original  receptacle.  This 
new  capsule,  which  entirely  surrounds  the  head  of  the 
femur  in  its  new  position,  is  of  a  hbro-ligaineiitous 
character,  mixed  in  some  points  with  a  considerable 
quantity  of  yellowish,  dense,  adipose  structure.  (]'/</> 
Plate  vir.)  It  is  inelastic,  but  from  the  length  of  its 
fibres,  free  motion  of  the  bone  is  allowed  in  even  direction 
after  the  muscles  have  been  removed  Internally,  it  is 
attached  to  the  margin  of  an  oval  depression  situated  on 
the  dorsum  of  the   ilium   in   front  of  the   iscbiatic   notch  ; 

13 


186  PATHOLOGY. 

externally,  it  has  formed  adhesions  with  the  annular  per- 
foration in  the  ancient  capsule,  through  which  the  head 
of  the  bone  has  passed.  The  external  surface  of  the 
capsule  is  generally  surrounded  by  a  cellulo-adipose  tissue, 
but  above,  it  is  confounded  with  the  fibrous  structure  of 
the  deep  surface  of  the  gluteus  minimus,  and  below,  with 
the  outer  and  superior  part  of  the  original  capsule.  The 
internal  surface  of  the  new  capsular  ligament  is  smooth 
and  shining,  studded  in  various  points  with  numerous 
pediculated  granular  bodies  of  a  yellowish  adipose  ap- 
pearance, and  at  the  lower  and  external  portion,  may  be 
observed  the  perforation  already  mentioned,  and  which  is 
seen  to  allow  a  free  communication  between  the  ancient 
capsule  and  the  one  of  more  recent  formation.  Within 
the  cavities  of  both  capsules  a  considerable  quantity  of 
synovial  liquid  is  found,  which  most  probably  has  been 
secreted  from  the  lining  membrane  of  the  original  cap- 
sule. 

The  ligamentum  teres,  most  likely  after  being  ruptured 
or  worn  through,  on  account  of  the  stretching  it  must  have 
undergone  by  the  displacement  of  the  parts,  has  entirely 
disappeared,  leaving  no  trace  of  its  existence  behind, 
either  at  its  attachment  to  the  head  of  the  femur,  or  at 
the  bottom  of  the  cotyloid  cavity. 

The  head  of  the  femur  has  changed  its  character  in 
regard  to  its  size,  shape,  and  consistence.  Its  dimensions 
are  much  smaller  than  natural,  being  at  least  one  third 


PATHOLOGY.  187 

below  the  natural  standard.  ( Vide  Plate  vii.)  Th<- 
aspect  upon  which  the  round  ligament  is  generally 
attached,  is  flattened,  and  seems  either  to  have  never 
been  developed  in  this  direction,  or  to  have  been  absorbed, 
or,  as  it.  were,  worn  down  by  the  friction  to  which  it 
must  have  been  subjected  upon  the  dorsum  of  the  ilium 
during  progression.  This  flattened  aspect  presents  super- 
ficially a  thin  lamina  of  bone,  which  is  entirely  denuded 
of  articular  cartilage,  and  on  the  surface  of  which  are 
seen  numerous  irregular  elevations  and  depressions  per- 
forated with  small  foramina,  as  if  the  subjacent  cancel- 
lated tissue  had  been  encroached  upon.  The  osseous 
tissue  of  what  remains  of  the  head  of  the  femur  is  en- 
tirely altered.  Instead  of  the  spherical  form  and  resisting 
tissue  of  the  adult  normal  bone,  the  head  of  the  femur  in 
the  subject  before  us  presents  an  unshapely,  stunted 
appearance,  covered  externally  by  a  thin,  friable,  osseous 
shell,  which  lies  upon  a  spongy,  cellular  tissue  of  bone,  so 
soft  as  to  be  easily  crushed  between  the  fingers,  and  inca- 
pable of  resisting  the  pressure  of  a  common  writing  quill. 
The  articular  cartilage  exists,  but  to  a  very  limited  extent, 
and  is  seen  to  end  abruptly  in  a  greyish  undulating  line, 
leaving  that  portion  of  the  head  in  contact  with  the  dor- 
sum of  the  ilium,  as  has  already  been  mentioned,  entirety 
bare.  The  neck  of  the  femur  is  shorter  and  more  slen- 
der than  natural,  and  forms  a  right  angle  with  the  shaft 
of  the   bone,   which   arrangement,   however,  may  in  part 


188  PATHOLOGY. 

be  accounted  for  by  the  advanced  age  of  the  patient. 
The  ancient  acetabula  present  changes  no  less  remark- 
able than  the  corresponding  heads  of  the  femurs  which 
have  escaped  from  them.  Instead  of  the  round  cup-like 
cavity,  there  is  seen  a  triangular  depression,  not  more 
than  half  an  inch  in  depth,  and  two  and  three-quarter 
inches  in  perimeter.  (Vide  Plate  vi.)  The  upper  and 
inferior  borders  of  this  triangle  are  nearly  equal  in  length, 
but  the  inner  is  shorter,  and  presents  an  excurvation, 
which  is  probably  the  remains  of  the  notch  on  the  mar- 
gin of  the  acetabulum,  for  the  passage  of  the  articular 
vessels  into  the  joint.  This  notch  is  crossed  by  a  trans- 
verse ligament,  which  completes  the  border  of  the  cavity, 
but  the  cotyloid  ligament,  whose  use  in  the  natural  state 
of  the  parts  is  to  deepen  the  acetabulum,  exists  but  in  a 
rudimentary  manner.  To  the  margin  of  the  acetabulum 
thus  constituted,  is  attached  the  pelvic  portion  of  the  old 
capsular  ligament.  The  capsular  ligament,  in  its  passage 
across  the  cotyloid  cavity  to  be  attached  to  the  cervix 
femoris,  becomes  immediately  connected  with  the  cellulo- 
adipose  tissue,  which  fills  up  that  depression ;  still,  by 
reason  of  its  distinct  fibrous  structure,  it  can  be  distinctly 
traced  to  its  attachments  at  the  margin  of  the  acetabulum. 
The  bottom  of  the  acetabulum  is  entirely  ossified,  show- 
ing no  signs  of  an  arret  de  developpement.  There  is  no 
remains  of  the  ligamentum  teres,  and  what  fills  up  the 
cavity  may  be  said  to  have  a  resemblance  to  the  fatty 


PATHOLOGY.  189 

mass  usually  situated  at  the  bottom  of  the  acetabulum, 
and  which  lias  received  the  name  of  the  glands  of 
Havers. 

There  is  no  new  cavity  formed  for  the  head  of  the 
femur  in  its  new  position,  as  might  he  supposed,  hut  on 
the  dorsum  of  the  ilium,  in  front  of  the  upper  part  of  the 
sciatic  notch,  there  exists  an  oval  depression  of  about  an 
eighth  of  an  inch  in  depth  at  its  centre,  and  which  is 
excavated  at  the  expense  of  the  ilium.  (Vide  Plate 
vn.)  The  head  of  the  bone  has  played  on  this  surface 
during  life,  and  has  probably  determined  this  species  of 
depression.  The  circumference  of  this  depression  receives 
the  attachment  of  the  new  capsular  ligament,  the  fibres 
of  which  extend  in  a  radiating  manner,  and  becom- 
ing confounded  with  the  periosteum,  have  the  appearance 
of  lining  its  floor,  except  at  the  centre,  where  the  friction 
of  the  two  bones  against  each  other  must  have  been 
greatest;  there  the  osseous  tissue  is  entirely  denuded,  and 
at  this  point  the  ilium  appears  to  be  almost  perforated. 
It  will  be  seen  that  there  has  been  no  attempt  at  the 
formation  of  a  new  socket  by  ossific  effusion  from  the 
surface  of  the  ilia,  as  generally  takes  place  in  those 
instances  of  traumatic  dislocation  which  have  not  been 
reduced.  This  is  particularly  worthy  of  remark,  as  M. 
Jules  Guerin,  of  Paris,  has  stated  that  the  deposition  of 
new  bony  material,  as  an  effort  to  form  a  uew  acetabu- 


190  PATHOLOGY. 

lum,  was  an  invariable  result  in  those  cases  of  congenital 
luxation  where  the  original  capsular  ligament  had  been 
ruptured  or  torn,  so  as  to  allow  the  head  of  the  femur  to 
escape,  and  it  is  from  this  supposition,  erroneous,  as 
proved  by  the  case  now  under  consideration,  that  he  has 
deduced  certain  principles  of  treatment  for  these  congeni- 
tal affections  of  the  hip-joint. 

These  are  the  principal  alterations  which  are  found  to 
have  taken  place  in  the  soft  tissues,  and  at  the  ancient  and 
recent  articulations ;  but  the  changes  of  form  and  dimen- 
sion which  the  bones  of  the  pelvis,  taken  collectively, 
have  undergone,  merit  also  consideration,  especially  in  a 
therapeutic  point  of  view,  and  in  relation  to  the  passage 
of  the  head  of  the  child  during  parturition.  After  the 
description  which  has  been  given  of  the  muscles  and  of 
their  abnormal  direction,  it  is  not  difficult  to  suppose  that 
the  diseased  retraction,  as  well  as  their  physiological 
action,  and  the  superincumbent  weight  of  the  body,  act- 
ing conjointly,  would  modify,  more  or  less,  the  natural 
shape  of  the  bones  under  these  influences  during  the  early 
periods  of  infancy,  while  the  osseous  tissue  was  yet  not 
completely  consolidated.  In  analyzing  the  changes 
which  the  parts  have  undergone,  most  of  the  deviations 
in  inclination,  form,  and  dimension,  can  in  a  great  degree 
be  referred  to  the  abnormal  direction  in  which  the  mus- 
cles have  been  obliged  to  act  after  the  displacement  of  the 


PATHOLOGY.  IP] 

bead  of  the  bone  upon  the  dorsum  of  the  ilium  has  taken 
place.  It  will  be  seen  that  the  pelvis  generally  is  more 
slender,  in  its  construction,  the  osseous  texture  at  the  same 
time  being  less  compact,  owing  probably  to  an  original 
and  continued  diminution  of  nervous  and  vascular  supply. 
Vide  Plates  vi.  and  vir. 

In  comparing  the  denuded  pelvis  with  that  of  the 
healthy  female,  the  most  prominent  difference  observed,  in 
a  practical  point  of  view,  is  that  between  the  upper  and 
lower  straits.  In  the  present  pathological  specimen  the 
upper  strait  is  found  to  be  generally  below  the  usual 
measurements,  both  in  the  transverse  and  anteroposterior 
diameters;  the  latter,  however,  is  proportionally  much 
more  contracted  than  the  former.  In  a  dried  healthy 
female  pelvis  before  me,  the  transverse  diameter  is  five  and 
a  quarter  inches,  while  in  the  morbid  specimen  it  is  four 
and  seven-eighths  inches;  the  autero-posterior  diameter 
in  the  natural  specimen  is  three  and  seven-eighths  inches; 
in  the  other  instance,  it  is  only  two  and  three-quarter 
inches. 

The  inferior  strait  in  the  morbid  pelvis  is  still  more 
anomalous.  Between  the  apex  of  the  coccyx,  and  the 
arch  of  the  pubes,  the  measurement  is  one  and  seven- 
eighths  inches,  against  four  inches  in  the  healthy  pelvis  : 
while  the  distance  between  tin1  tuberosities  of  the  iscbia, 
making  up,  as  it  were,  for  the  small  antero-posteriof  dia- 
meter, is  live  and  three-eighths  inches  ;   the  ln\ilili\  pelvis 


192  PATHOLOGY. 

in  this  direction   being  only  four  and  a   quarter  inches. 
Vide  Plate  vii. 

The  wings  of  the  ilia  are  smaller  than  natural,  pre- 
senting angular  prominences  along  the  borders  of  the 
crests,  and  upon  the  dorsa  are  found  the  glenoid  depres- 
sions already  alluded  to,  where  the  heads  of  the  femurs 
had  played  during  life.  Immediately  below  the  anterior 
and  inferior  spinous  process  of  the  ilium  on  each  side,  the 
superficial  groove  in  the  healthy  bone,  over  which  the 
conjoined  tendons  of  the  psoas  magnus  and  iliacus  inter- 
ims passed,  is  converted  into  a  semicircular  deep  depres- 
sion or  gutter,  giving  a  more  than  usually  projecting  ap- 
pearance to  the  anterior  inferior  spine  of  the  ilium. 
The  descending  rami  of  the  pubes,  and  the  ascending 
rami  of  the  ossa  ischia  seem  spread  laterally,  and  pass 
almost  transversely  outwards,  giving  to  the  arch  of  the 
pubes  more  of  a  semicircular  appearance  than  of  an  ob- 
tuse angle,  which  is  observed  in  the  natural  condition  of 
this  part  of  the  osseous  structure.  (Vide  Plates  vi.  and 
vn.)  The  long  diameter  of  the  foramina  obturatoria, 
instead  of  running  nearly  parallel  with  the  body,  takes 
almost  a  transverse  direction. 

The  sacrum  is  somewhat  stunted,  showing  a  greater 
curvature  upon  its  anterior  aspect  than  in  the  natural 
bone,  and  at  its  junction  with  the  vertebral  column,  the 
sacro-vertebral  angle  is  seen  to  be  more  prominent  than 
usual.     The  spinal  column  in  the  lower  part  of  the  dor- 


PATHOLOGY.  L93 

sal  and  lambai  regions,  presents  anteriorly  a  remarkable 
convexity,  corresponding  to  the  concavity  seen  in  the  loins 
during  life. 

Although  the  superincumbent  weight  of  the  body,  and 
the  original  diseased  retraction  »>f  the  muscles  have  con- 
tributed  materially  to  the  production  of  the  changes,  just 

alluded  to,  in  the  direction  of  the  hones,  it  is  evident  that 
the  pelvi-trochanteric  muscles,  whose  course  and  manner 
of  action  have  become  entirely  altered  from  the  relative 
change  of  position  of  their  points  of  origin  and  insertion, 
after  the  heads  of  the  femurs  have  been  dislocated,  and 
ascended  on  the  dorsa  of  the  ilia,  must,  in  the  ordinary 
performance  of  their  functions,  have  aided  somewhat  in 
bringing  about  those  deviations  in  direction  and  inclina- 
tion, which  the  component  parts  of  the  pelvis  have  now 
assumed,  so  different  from  what  is  to  be  seen  in  one  na- 
turally   constructed.      The   head   of    the    femur    having 

J  O 

slipped  upon  the  dorsum  of  the  ilium,  it  is  easj  to  nip- 
pose  that  in  progression,  the  lower  dorsal  and  lumbar  ver- 
tebrae would  be  pulled  forwards  \x)  the  action  of  the 
psoas  magnus,  while  the  deep  gutter  observed  on  the  brim 
of  the  pelvis  below  the  anterior  inferior  spine  of  the  ilium, 
is  no  doubt  caused   l>\   the  conjoined  tendon S  of  the  psoas 

magnus  and  iliacus  internus  playing  like  a  pulley  in  this 
depression;  these  muscles  being  almost  continual!]  in  a 
state  of  tension,  owing  to  the  increased  distance  of  the 

small  trochanter,  since  the    ascent   of  the  femur  upon   the 


194  PATHOLOGY. 

ilium.  The  same  muscles  will  also,  in  acting  on  both 
sides,  flatten  or  depress  the  brim  of  the  pelvis,  and  thus 
the  antero-posterior  diameter  is  reduced ;  and  in  con- 
nexion with  the  relaxed  state  of  the  gluteus  minimus  and 
medius,  the  iliacus  internus  by  its  contractions  will  tend 
to  render  the  wing  of  the  ilium  more  vertical.  The 
psoas  magnus,  through  the  medium  of  its  connexion  with 
the  lumbar  vertebrae,  tilting  forward  the  base  of  the 
sacrum,  and  the  conjoined  tendons,  in  their  passage  to 
their  insertion,  pushing  downwards  and  backwards  the 
brim  of  the  pelvis,  conduce  to  change  the  axes  of  the 
pelvis,  and  to  render  nearly  vertical,  in  the  erect  posture, 
the  crests  of  the  ilia.  The  increased  transverse  diameter 
of  the  inferior  strait  and  the  almost  horizontal  direction 
of  the  rami  of  the  pubes,  and  of  the  ischia,  where  they 
form  the  arch,  as  well  as  the  outward  direction  and  in- 
creased separation  of  the  tuberosities  of  the  ischia,  can  be 
accounted  for  by  the  perverted  action  of  the  quadratus 
femoris,  the  gemelli,  the  obturatores,  and  perhaps  the  upper 
fibres  of  the  adductor  magnus.*  Vide  Plates  vi. 
and  vii. 

The  case  just  related  presents  comparatively  but  little 
complication  beyond  the  dislocation  itself;  in  another, 
which  I  had  an  opportunity  of  examining,  and  which  I 
now  introduce,   complications   of  various    kinds  will  be 

*  This  case  was  originally  furnished  by  me  to  the  N.  Y.  Journal  of  Medicine,  and 
published  in  the  XXXI.  No.,  for  July,  1848. 


/£ 


liA    >fS*--onyl:Mcjt 


EXPLANATION  OF  PLATE  No.  VIII 

Antero-latcral  view  of  a  Male  Pelvis,  with  Double  Congenital  Dislocation  of  the 
Femurs  upon  the  Dorsa  of  the  Ilia,  from  a   person   aged  about   sixty. 

A.  The  right  Femur  deformed,  bent,  and  stunted. 

B.  The  left  Femur  stunted  and  fractured  towards  its  upper  extremity. 
a.  Anterior  Superior  Spinous  process  of  the  Ilium. 

I).   Anterior  Inferior  Spinous  process  of  the  Ilium. 

c.  Deep  Groove  under  the  Anterior  Inferior  Spinous  process  of  the  Ilium,  in  which 

has  played  the  conjoined  tendon  of  the  Psoas  Magnus  and  Iliaeus  Internes. 

d.  The  remains  of  the  Head  and  Neck  of  the  right  Femur,  now  atrophied.     The 

old  Capsular  Ligament,  now  converted    into  a  cord-like   structure,  is    firmly 
inserted  into  the  upper  extremity  of  the  Femur. 

r.  The  Ancient  Capsular  Ligament  agglomerated  into  a  dense  fibrous  Ligamentous 

Cord.     The  Ligamentum  Teres  may  have  become  incorporated  with  the  fibrous 

Cord. 
/.  The  margin    of   a  small  oval-shaped  cavity  in   the  Original  Capsule,  which  ia 

laid  open  by  removal  of  its  Anterior  Wall. 
g.  The  remains  of  the  Ancient  Acetabulum,  which  is  contracted,  and  tilled  with  a 

softish  adipo-osscous  material,  penetrable  by  a  probe  for  nearly  an  ineh. 
h.  Ligamentum  Patellae. 

j.  Inferior  extremity  of  the  Femur  partially  luxated. 
k.  Tibia  and  Fibula  participating  in  the  oseeoufl  degeneration. 


J.  lc/%  of  Sctrty  *  Maje 


EXPLANATION  OF  PLATE   No.  IX 

Posterior  view  of  the  same  pelvis,  with  Double  Congenital   Dislocation   of  the 
Femurs  upon  the  Dorsa  of  the  Dia. 
\     Eli  rhl  Femur  degenerated  in  its  tissue — Head  and  Neck  atrophied. 

('•    Left  Femur — its  tissues  also  degenerated — the  Head  and  Neck  have  entirely  die 

appeared — the  upper  part  of  the  Shaft  has  been  fractured  by  muscular  traction. 

</.  Dorsum   Ilii. 

b.  Remains  of  the  Head  and  Neck  of  the  right  Femur. 

c.  Trochanter  Major. 

'/.  Tendinous  insertion  of  the  Pelvi-Trochanteric  Muscles. 

r.   Abrupt   termination  of  the  Shaft  of  the  left  Femur  at  the  point  of  Fractun-. 

/,  Pseudo-articulation,  laid  open,  between  the  fractured  portions  of  the  Shaft  of 
the  Femur. 

?.  New  Ligamentous  Structure  attached  by  radiating  fibres  to  the  Dorsum  of  the 
Ilium,  and  becoming  incorporated  with  the  posterior  surface  of  the  Original 
Capsule,  B0  :i-  to  form  in  part  the  Ligamentous  Cord  upon  which  the  supor- 
incumbenl  weight  of  the  Trunk  lias  been  chiefly  thrown  during  r 

A.  Inferior  extremity  <>f  the  Femur  partially  Luxated  from  the  Tibia. 

,-.  Tuberosity  <'t  the  Ischium. 

it.   Tibia  ami   Fibula,  smaller  and  less  dense  in   Structure  than  is  natural. 


PATHOLOGY.  J  09 

met  with,  which  have  occurred  ;is  consequences  of  the 
primarj  exarticulation  of  the  head  of  the  femur. 

The  subject  was  a  male,  of  about  sixty  years  of 
age,  and,  as  may  be  inferred  from  tin'  annexed  drawing  of 
the  pelvis,  and  the  ossa  femora  appertaining  to  it,  as  pre- 
sented in  Plates  viii.  and  i\..  exhibited  during  life  a  de- 
formity of  a  remarkable  kind. 

The  trunk  was  tolerably  well  developed,  but  from  the 
region  of  the  pelvis  downwards  to  the  tibio-tarsal  articu- 
lation, on  both  sides,  the  aberration  from  the  usual  forma- 
tion was  carried  to  an  extraordinary  extent.  The  pecu- 
liar appearance  of  the  nates,  the  mobility,  and  other  signs 
observable  at  the  ilio-femoral  articulation,  indicated  the 
existence  of  the  congenital  form  of  dislocation  upwards 
and  outwards  of  the  femurs,  at  this  joint.  Besides  the 
change  in  the  relations  of  the  component  parts  of  the 
articulations,  the  appearance  of  the  thighs  showed  the 
existence  of  complications  which  may  sometimes  occur  in 
the  later  periods  of  this  displacement. 

The  inferior  members  on  each  side  could  be  pulled 
downwards  or  pushed  upwards  on  the  dorsum  ilii,  over  a 
space  of  about  three  inches,  and  on  account  of  the  atro- 
phied state  of  the  upper  portions  of  the  ossa  femora, 
the  stunted  superior  portions  only  of  these  bones  could  be 
discovered  during  the  rotation  or  flexion  of  the  limb. 
The  tuberosities  of  the  ischia  could  be  fell  denuded  of 
their  muscles,  and  separated  from  each   other  much   far- 


200  PATHOLOGY. 

ther  than  is  seen  in  the  normal  pelvis.  The  thighs  are 
of  unequal  length,  that  of  the  left  side  being  the  shorter, 
notwithstanding  the  curvature  which  exists  on  that  of 
the  opposite  side.  The  femoro-tibial  articulation  is  par- 
tially luxated,  and  the  legs  also  present  appearances  of 
malformation,  which  is  increased  by  the  disposition  of 
the  parts  at  the  tibio-tarsal  articulation. 

The  skin,  cellular  tissue,  muscles,  arteries,  veins,  and 
nerves  presented  the  same  characteristics  which  were 
pointed  out  as  existing  in  the  dissection  of  the  preceding 
case ;  it  will  therefore  be  unnecessary  to  reconsider  these 
structures  in  the  present  instance.  I  shall  therefore  only 
describe  the  appearances  and  changes  in  the  ligamentous 
and  osseous  structures  of  the  joint  itself,  and  of  the  skele- 
ton in  contiguity  to  it. 

Capsular  Ligament. — Instead  of  the  natural  and  capa- 
cious capsule,  a  dense  fibrous  structure  extends  from  the 
natural  locality  of  the  acetabulum  to  the  upper  portion  of 
the  femur,  to  which  it  is  firmly  attached,  grasping,  as  it 
were,  the  superior  part  of  this  bone,  on  either  side.  This 
structure  extends  from  the  pelvis  to  the  upper  portion  of 
the  femur,  and  from  the  position  it  occupies,  must  be 
considered  as  the  perverted  remains  of  the  original  cap- 
sule which  has  become  converted  into  a  strong  fibro-liga- 
mentous  cord,  entirely  solid,  with  the  exception  of  a  small 
oval  cavity,  situated  opposite  the  old  acetabulum.     This 


PATHOLOGY.  201 

cavity  is  little  more  th;in  half  an  inch  in  diameter,  is  lin  'I 
by  a  smooth  synovial  surface,  and  from  its  situation  and 
relations  to  the  place  where  the  remains  of  the  anci<  al 
cotyloid  cavity  are  seen,  is  evidently  the  representa- 
tive of  the  large  articular  cavity  which  the  capsular  liga- 
ment presents  under  ordinary  conditions.  Vide  i'i  \n 
viii. 

The  weight  of  the  trunk  has  been  supported  mainly 
by  this  strong  ligament  during  progression;  and  the 
attachments  it  has  formed  to  the  ilium  and  to  the  femur 
are  exceedingly  firm  and  extensive.  In  front,  it  takes  its 
origin  from  that  portion  of  the  ilium  where  the  acetabu- 
lum would  naturally  exist,  and  from  the  osseous  suri 
contiguous  to  the  anterior  inferior  spinous  process  of  the 
ilium,  and  becoming  ligamentous  at  the  outer  part  of  the 
small  cavity  mentioned,  it  ascends  upwards  and  outwards 
for  the  distance  of  about  three  inches,  to  become  strongly 
attached  to  the  upper  extremity  of  the  femur  of  both 
sides.  On  the  right  side,  it  grasps  the  atrophied  remains 
of  the  head  and  neck  of  the  femur,  and  on  the  left,  the 
abrupt  termination  of  the  upper  portion  of  the  shaft  oi 
the  femur,  which  on  this  side  lias  been  fractured  bj  mus- 
cular traction.  On  the  left  side,  where  its  attachments 
to  the  femur  are  formed,  it  encloses  a  small  portion  ot 
bone,  the  remains  of  the  upper  fragment  <>f  the  fractured 
shaft.  This  upper  fragment  rests  horizontally  among  tli« 
fibres  of  the  ligamentous  cord,  and  presents  a  plane  sur- 

14 


202  PATHOLOGY. 

face,  opposed  to  a  corresponding  smooth  surface,  which  is 
met  with  on  the  inner  aspect  of  the  superior  end  of  the 
lower  fragment  of  the  shaft.  The  fibres  of  this  ligamen- 
tous cord,  as  they  become  attached  to  the  deb?-is  of  the 
upper  portion  of  the  femur,  extend  in  a  diverging  man- 
ner over  the  place  where  the  two  fragments  lie  in  contact. 
{Vide  Plate  ix.)  During  progression  these  contiguous 
osseous  surfaces  must  have  been  subjected  to  continued 
friction  upon  each  other.  There  has  been  no  attempt  at 
union  between  them,  but  a  moveable  pseudo-articulation 
has  resulted,  invested  by  the  fibres  of  the  femoral  attach- 
ments of  the  cord-like  ligament,  and  lined  internally  by  a 
smooth  thin  membrane. 

Besides  the  attachments  already  spoken  of  as  arising 
from  the  site  of  the  old  acetabulum,  the  cord-like  ilio- 
femoral ligament  receives  a  numerous  accession  of  fibres, 
which  take  their  origin  in  a  radiating  form  from  the  dor- 
sum ilii,  and  from  the  osseous  surface  adjacent  to  the 
anterior  inferior  spine  of  the  ilium.  These  auxiliary 
fibres  converge,  and  become  incorporated  with  the  other 
fibres  of  the  ligament,  whence  results  the  strong  fibrous 
cord  running  from  the  ilium  to  the  femur.  The  ligamen- 
tum  teres  has  most  probably  become  agglomerated  with 
the  coalesced  capsule,  or  it  may  have  disappeared  by  ab- 
sorption. 

The  Acetabulum. — The  alterations  which   have  taken 


PATHOLOGY.  203 

place  at  the  acetabulum  arc  so  considerable  as  to  have 
destroyed  nearly  every  vestige  of  it  In  examining  the 
locality  where  the  three  primary  hours  unite  to  form  the 
cotyloid  cavity,  at  first  view  nothing  is  mel  with  af  all 
analogous  to  the  large  articular  surface  of  the  healthj 
acetabulum.  Upon  close  inspection,  however,  a  small 
depression  is  seen.  Upon  farther  examination,  this  de- 
pression is  found  not  to  be  the  limit,  but  the  entrance,  as 
it  were,  to  a  contracted  cavity,  which  is  filled  up  by  a 
soft  semi-osseous  deposit  only.  This  semi-osseous  mate- 
rial can  be  easily  perforated  to  the  depth  of  an  inch,  by  a 
probe  which,  passing  thus  far,  becomes  impeded  in  its 
progress  by  an  osseous  tissue  of  a  dense  character.  This 
kind  of  osseous  canal,  extending  in  the  direction  of  the 
primary  acetabulum,  is  all  that  remains  to  represent  the 
ancient  cotyloid  cavity.  The  soft  osseous  materia]  can 
be  broken  down  with  facility,  and  then  the  real  bonj 
limits  of  the  depression  are  seen  to  approach  somewhai 
to  a  triangular  shape. 

The  disposition  of  the  parts  observed  ai  the  right  ace- 
tabulum is  the  same  at  the  left,  with  slight  modifications. 
The  soft  osseous  tissue  Idling  up  the  cavitj  cannot  be 
penetrated  for  more  than  half  an  inch,  and  the  borders 
or  limits  of  the  altered  acetabulum  are,  consequently, 
still  more  contracted  than  on  the  other  side. 

Tht    Head  of  tin    Femur. — The   superior  extremities 


204  PATHOLOGY. 

of  both  femurs  are  entirely  altered  in  shape  and  dimen- 
sions. 

On  the  right  side  the  head  and  neck  have  disappeared. 
The  upper  portion  of  the  femur  has  become  curved,  so 
that  the  trochanter  major  takes  an  inward  direction 
towards  the  ilium,  and  receives  the  attachments  of  the 
ligament  which  now  takes  the  place  of  the  capsular  liga- 
meut.  The  corresponding  portions  of  the  left  femur  pre- 
sent appearances  which  are  extremely  abnormal.  The 
upper  portion  of  the  remaining  shaft  terminates  abruptly, 
and  not  the  slightest  trace  of  the  head  or  neck  remains. 
The  upper  portion  of  the  shaft  has  been  fractured  from 
the  muscular  tractions  exercised  upon  .the  bone,  the  struc- 
ture of  which  had  no  doubt  previously  become  softened 
and  atrophied.  The  upper  fragment,  deprived  of  nutri- 
tion, has  gradually  disappeared,  excepting  a  small  portion 
only.  This  is  pulled  horizontally  inwards,  at  right 
angles  with  the  lower  fragment,  and  it  presents  a  smooth 
surface,  which  lies  in  apposition  with  the  inner  aspect  of 
the  superior  end  of  the  other  portion.  The  ligamentous 
cord,  attached  on  one  side  to  the  pelvis,  on  the  other, 
grasps  the  upper  extremity  of  the  femur,  in  such  a  way  as 
to  maintain  the  surfaces  of  the  fragments  in  contact,  and 
thus  a  pseudo-articulation  is  formed  between  the  upper 
and  lower  fragments  of  the  broken  shaft.      Vide  Plate  ix. 

These   extraordinary  alterations,  which  the  upper  por- 
tions of  the  ossa  femorum  have  undergone,  are.  altogether 


PATHOLOGY. 

unaccountable,  except  by  taking  into  consideration  the 
pathological   conditions  which    must    supervene  in    the 

osseous  structure  of  these  bones,  from  the  diminished 
nutrition  with  which  they  are  supplied,  soon  after  the 
head  of  the  femur  is  exarticulated  from  its  natural  recep- 
tacle, and  has  ascended  upon  the  ilium.  If  this  circum- 
stance be  kept  in  mind,  it  will  not  appear  strange  thai  tie- 
heads  of  the  femurs,  deprived  early,  as  they  musl  have 
been,  of  nearly  all  vascular  supply  by  the  compression 
or  destruction  of  the  ligamentum  teres,  should  become 
atrophied,  and  ultimately  disappear. 

The  reduction  of  the  calibre  of  the  arterial  tubes, 
which  has  been  mentioned  as  obtaining  in  cases  of  con- 
genital dislocation  at  the  hip-joint,  and  the  consequent 
impoverished  supply  of  blood  to  the  osseous  tissue  of  the 
other  portions  of  the  femur,  will  explain  the  existence  of 
that  friable  and  atrophied  condition  of  the  osseous  tissue. 
from  which,  owing  chiefly  to  muscular  tractions,  has 
resulted  the  fracture  of  the  shaft  of  the  left  femur.  The 
almost  total  disappearance  of  the  upper  fragment  must 
also  be  the  result  of  its  isolation  from  the  sources  of  nutri- 
tion, after  it  has  become  detached   from    the  oilier  part    of 

the  lemur.     The   right    femur,  suffering   fr tie'  same 

causes,  has  not  been  fractured,  but  is  curved  in  the  direc- 
tion of  the  muscular  action,  which  has  been  aided  proba- 
bly by  the  influence  of  the  superincumbent  weight  of  the 
trunk. 


206  PATHOLOGY. 

Dorsum  Ilii.  New  Capsule.  New  Socket. — In  the 
description  given  of  the  post-mortem  appearances  of  the 
previous  case,  the  dorsum  ilii  was  represented  as  being 
occupied  by  the  attachments  of  the  new  capsule,  by 
which  the  head  of  the  femur  had  become  enveloped  after 
its  escape  from  its  original  capsule.  In  the  case  which 
now  claims  our  attention,  the  head  on  either  side  had 
never  passed  from  the  capsular  ligament.  The  head  of  the 
femur  appears  to  have  become  absorbed,  and  the  cavity  of 
the  capsule  contracting  pari  passu,  as  the  head  disap- 
peared, has  become  agglutinated,  and  ultimately  converted 
into  a  strong  inelastic  fibrous  cord,  upon  which  devolved 
the  function  of  giving  the  chief  support  to  the  trunk  dur- 
ing progression.  The  attempt  to  form  a  new  capsule 
may  have  been  simulated  by  the  substitution  of  the  addi- 
tional ligamentous  fibres,  which  are  seen  to  spring  from 
the  dorsum  ilii,  and  to  converge  towards  the  posterior  sur- 
face of  the  old  capsule — or  rather,  of  the  cord-like  liga- 
ment, which  now  represents  the  capsule — with  the  fibres 
of  which  they  become  incorporated.  (Vide  Plate  ix.) 
The  disposition  of  these  converging  fibres,  which  take 
their  origin  from  the  ilium,  is  somewhat  analogous  to  the 
arrangement  of  the  fibres  which  contribute  to  the  forma- 
tion of  the  new  capsule  in  the  previous  case.  Vide 
Plate  vii. 

These  ligamentous   fibres,  originating  from  the  dorsum 
ilii,  are  the  only  substitute  nature  has  adopted  to  fortify 


P  LTHOLOGY. 

the  soft  parts,  which  alone,  in  this  case,  have  to  9upport 
the  weight  of  the  trunk,  in  the  absence  of  the  normal 
arrangement  at  the  ilio-femoral  articulation.  The}  are 
attached  to  the  space  of  about  an  inch  and  a  half  in  dia- 
meter upon  the  dorsum  ilii  ;  then-  is  no  depression,  how- 
ever, on  the  surface  of  the  ilium,  under  these  attachments. 
From  the  length  of  this  ilio-femoral  ligamentous  cord, 
thus  made  up,  the  upper  portions  of  the  ossa  femorum  must 
have  played,  during  progression,  along  the  external  sur- 
face of  the  ilium,  over  a  space  of  about  three  inches  in 
extent.  There  is  no  attempt  whatever  at  the  formation 
of  a  new  socket,  and  with  the  exception  of  a  slight 
groove,  caused  by  the  friction  of  the  upper  portion  of  the 
right  femur  upon  the  corresponding  dorsum  ilii,  there  is 
not  even  a  depression  present  for  the  lodgement  of  the 
femur.  As  in  the  former  case  described,  it  is  evident  that 
in  tin'  present  instance  also,  the  upper  parts  of  the  ossa 
femorum  could  have  had  no  lived  support  upon  the  surface 
of  the  ilium,  and  consequently,  during  the  acts  of  pro- 
gression, the  femurs  must  have  ascended  and  descended, 
according  as  the  weight  of  the  trunk  happened  to  be  throw  n 
upon  one  or  the  other  inferior  member. 

The  alterations  which  have  taken  place  in  the  skeleton 
of  the  pelvis,  as  a  consequence  of  the  displacement  of  the 
head  of  the  femur  upon  the  ilium,  are  similar  in  their 
general    characters   to    those   observed    in    the   case  before 


208  PATHOLOGY. 

described,  and  it  will  be  unnecessary  to  consider  them  as 
fully  in  the  present  instance. 

The  dislocation  being  double,  and  the  causes  of  mal- 
formation acting  with  nearly  equal  intensity  on  each  side, 
the  two  halves  of  the  pelvis  participate  almost  equally  in 
the  amount  of  deformity.  The  general  configuration  of 
the  pelvis  is  below  the  average  size,  and  the  bones  of  the 
ossa  innominata  are  thinner,  softer,  and  lighter  in  texture, 
than  the  corresponding  parts  taken  from  a  well  formed 
skeleton. 

The  wings  of  the  ilia  are  more  vertical,  thinner,  and 
flatter ;  the  sacrum  is  somewhat  narrower,  but  is  nearly  of 
the  natural  size.  The  pelvis  towards  the  pubic  region  is 
somewhat  salient ;  and  owing  probably  to  the  greater 
amount  of  muscular  traction  exerted  on  the  side  where 
the  femur  had  suffered  most,  the  corresponding  horizontal 
branch  of  the  pubes  between  the  symphysis  and  the  infe- 
rior spine  of  the  ilium  is  longer  by  about  three-eighths  of 
an  inch  than  on  the  opposite  side. 

The  foramina  obturatoria  have  their  long  diameters 
thrown  into  a  direction  almost  transversal.  The  groove 
between  the  anterior  inferior  spinous  process  of  the  ilium, 
and  the  eminentia  ilio  pectinea,  for  the  lodgement  of  the 
tendon  of  the  psoas  magnus  and  iliacus  internus,  is  seen 
to  be  exceedingly  deeply  impressed. 

The  tuberosities  of  the  ischia  are  retracted  outwards, 


t kTHOLOOl . 

and  for  ;i  male  pelvis  present  an  unusuallj  large  measure- 
ment betweeo  them.      Vidi    Plate  ix. 

Diameters  of  the  Pelvis. — Like  the  female  pelvis,  pre- 
viously described,  the  diameters  of  the  male  pelvis  in  this 

case  are  perverted  by  the  malformation  which  occurs 
consequent  upon  the  dislocation  of  the  femur  upon  th< 
ilium.  This  circumstance  in  the  male  is  of  hut  little 
consequence,  but  it  confirms  the  opinion,  I  have  already 
expressed,  that  malformation  of  the  pelvis  is  an  invari- 
able accompaniment  of  this  form  of  congenital  dislocation 
of  the  femur  upon  the  ilium. 

I1  he  statement  simply  of  the  measurements  of  the 
pelvis,  from  which  this  description  is  taken,  will  be  suffi- 
cient at  present,  without  again  giving  the  comparative 
measurements  of  the  well  formed  pelvis.  They  are  as 
follows  :  From  one  anterior  superior  spinous  process  of 
the  ilium  to  the  other,  seven  and  five-eighths  inches ; 
from  the  anterior  superior  spinous  process  of  the  ilium  ft 
the  symphysis  pubis,  on  the  right  side,  five  inches  ;  on  the 
left  side,  four  and  five-eighths  inches;  transverse  diameter 
of  the  superior  strait,  four  and  a  quarter  inches  :  from  the 
promontory  of  the  sacrum  to  the  symphysis  pubis,  t! 
and  one-eighth  inches. 

At  the   inferior  strait,  the  transverse  diameter  betv 
the  inner  side  of  one  tuberosity    <>!  the  ischium  to  thai  of 
the  other,  lour  and  three-quarter  inches;  while  the  antero- 


210  PATHOLOGY. 

posterior  diameter,  from  the  point  of  the  coccyx  to  the 
arch  of  the  pubes,  is  two  and  three-quarter  inches. 

The  depth  of  the  pelvis  anteriorly  from  the  highest 
part  of  the  ramus  of  the  pubes  to  the  corresponding  tube- 
rosity of  the  ischium,  is  three  inches,  and  from  the  pro- 
montory of  the  sacrum  to  the  point  of  the  os  coccygis,  it 
is  four  inches. 

These  measurements  show  that  the  pelvis,  taken  as  a 
whole,  does  not  present  the  average  dimensions,  and  that 
the  contractions  observable  are  proportionally  greater  in 
the  antero-posterior,  than  in  the  transverse  measurements. 

The  various  influences,  such  as  the  shortening  of  the 
morbidly  affected  muscles,  the  influence  of  the  superin- 
cumbent weight  of  the  body  during  progression,  and  the 
ordinary  muscular  contractions  which  have  contributed, 
either  separately  or  conjointly,  to  increase  the  malforma- 
tion of  the  pelvis  and  of  the  other  adjacent  bones,  need 
not  be  recapitulated  ;  nor  need  the  analysis  of  the  deformi- 
ties of  the  individual  parts  of  the  pelvis,  and  of  the  action  of 
certain  muscles  in  producing  them,  be  repeated  in  this  place, 
since  the  subject  has  been  fully  considered  in  the  descrip- 
tion of  the  preceding  case  of  this  dislocation. 

It  must  be  recollected,  however,  particularly  in  regard 
to  cases  like  the  present,  where  the  malformation  is  so  exten- 
sive, that  these  various  causes  owe  much  of  their  effi- 
ciency to  the  deteriorated  condition  of  the  osseous  struc- 
ture of   the  pelvis   and   of  the  other  contiguous  bones, 


PATHOLOGY.  2  I   1 

which  either  accompanies  or  results  from  the  displacement 

of  the  head  of  the  femur. 

It  is  evident,  as  the  result  of  these  investigations,  thai 
there  is  a  wide  range  in  the  morbid  alterations  which 
take  place  in  the  progress  of  congenital  dislocations  of  the 
femur  upon  the  ilium,  from  the  simple  changes  in  the 
initiatory  stage,  to  the  extreme  complications  presented 
in  this  last  case,  but  the  general  pathological  principles 
upon  which  they  depend,  I  trust  have  been  fully  set 
forth. 


EXPLANATION  OF  PLATE  A. 

This  plate  represents  the  Apparatus  of  Sustentatioo,  upon  which  the  patient  reposes 
while  the  preparatory  extension  is  being  made  to  bring  down  the  head  of  the 
femur  opposite  the  acetabulum. 

a.  Arch  opening  at    the  centre,  by  means  of   a  hinge  on  each  side,  passing  over 

the  patient,  so  as  to  give  attachment  to  the  strap  of  counter  exti 

b.  The  strap  for  making  the  counter  extension  attached  interiorly  t'>  the  plan 

the  bod,  and  passing  from  without  inwards  and  upwards  to  n-  superior  attach- 
ment at  the  centre  of  the  arch. 

c.  Two  crutch-like  supports  well  padded,  upon  which  the  axillae  rest 

d.  Encasement    made    of   thick    leather,  padded,  and    furnished    with    straps    and 

buckles,  in  winch  «he  limb  is  placed  and  retained. 

e.  Hook  fixed  to  the  leather  encasement,  for  the  attachment  of  the  cord  of  exten- 

sion. 
/.  Cord  of  extension  passing  over  a  pulley  at  the  foot  of  the 
g.  Pulley  over  which  the  cord  passes. 

A.   Weight  attached  to  the  cord  of  extension,  and  by  which  the  extension  i-  kept  op. 
».  Cords,  attached  to  a  fixed  point  above  the  bed,  and  passing  along  its  -id.  -.     The 

plane  of  the  bed  being  movable,  the  patienl  by  polling  these  cords  ma] 

muscular  exercise,  without  interfering  with  the  extension. 


a  is 


CHAPTER  VIII. 

TREATMENT    OF    CONGENITAL    DISLOCATIONS    OF    THE    HEAD 
OF    THE    FEMUR. 

In  the  natural  condition  of  the  ilio-femoral  articulation 
a  reciprocal  harmony  of  configuration  of  a  most  perfect 
character  exists  between  the  head  of  the  femur  and  the 
cotyloid  cavity.  Under  ordinary  circumstances  these 
component  parts  of  the  joint  are  maintained  in  their 
normal  relations  by  the  pressure,  from  without,  of  the  atmo- 
sphere, by  the  ligamentous  connexions,  l>\  the  action  of 
the  muscles,  and  by  the  depth  of  the  cotyloid  cavitj . 

From  the  pathological  account  heretofore  given  of  the 
parts  implicated  in  congenital  dislocation  of  the  femur 
upon  the  ilium,  it  is  evident  that  the  mutual  adaptation  of 
the  various  structures  of  the  joint  is  early  disturbed, 
and  that  ultimately  the  alterations  become  so  extensive 
that  the  natural  relations  cannot  be  restored. 

Dupuytren,  reasoning  from  antopsic  examinations, 
generally  of  individuals  advanced  in  life,  was  of  opinion 


216  TREATMENT. 

that  permanent  reduction  of  the  head  of  the  femur  in 
cases  of  congenital  dislocation  was  beyond  the  reach  of 
art.  "  On  se  consolerait  aisement  de  ne  pas  connaitre  la 
cause  de  ces  deplacements,  si  Ton  connaissait  les  moyens 
de  les  faire  cesser,  ou  du  moins  de  pallier  leur  mauvais 
effets  ;  malheureusement  il  n'en  est  pas  ainsi,  et  ces  de- 
placements  ne  comportent  ni  remede  curatif  ni  meme  de 
palliatif  bien  efficace."  Notwithstanding  the  opinion 
of  the  celebrated  surgeon  of  the  Hotel-Dieu,  attempts 
have  been  made  in  more  recent  times  to  bring  about  per- 
manent reduction  of  the  head  of  the  femur  in  these 
cases,  and  in  some  instances  this  object  has  been 
attained. 

The  first  attempt  to  replace  permanently  the  head  of 
the  femur  at  the  acetabulum,  appears  to  have  been  made 
by  means  of  continued  extension,  by  MM.  Duval  and 
Lafond,  upon  a  child  nine  years  of  age,  affected  with 
double  congenital  luxation  of  the  femur  upon  the  ilium. 
The  results,  however,  of  this  case  do  not  appear  to  have 
been  satisfactory,  for  although  the  limbs  were  observed  to 
resume  their  proper  length  and  direction,  after  the  employ- 
ment of  extension  for  several  weeks,  yet  there  is  no  men- 
tion made  of  the  permanency  of  the  reduction. 

In  1835,  two  other  surgeons,  MM.  Humbert  and 
Jacquier,  who,  like  the  preceding,  confined  themselves 
specially  to  the  treatment  of  deformities,  in  a  publication 
issued  by  them  upon  the  mode   of  reducing  congenital 


TREATMENT.  217 

dislocations,  endeavored  to  prove  thai  the  component  parts 
of  the  articulation,  in  these  luxations  ai  the  hip-joint,  were 
not  always  so  entirely  changed,  as  to  preclude  the  possi- 
bility of  reduction,  and  supported  their  opinion  by  cases, 
in  which  the  treatment  was  said  to  bave  been  successful 
and  permanent  It  is  very  certain  thai  in  some  ol  those 
cases  the  head  of"  the  femur  was  forced  to  change  its 
position,  and  that  it  assumed  a  new  relation,  winch 
lessened  or  modified  the  lameness,  and  restored  the  limbs 
to  a  more  natural  length.  Doubts,  however,  have 
been  entertained  regarding  the  positive  success  ol  the 
reduction,  in  the  cases  reported  by  these  gentlemen, 
and  the  change  of  position  of  the  head  of  the  femur  has 
been  attributed  to  the  conversion  of  the  dislocation  upon 
the  ilium,  into  one,  where  the  bead  of  the  lemur  was 
thrown  into  the  ischiatic  notch,  Consequent  upon  the 
extension  and  force  made  use  of  to  effect  reduction. 
However  this  maj  be,  the  report  made  of  these  cases 
excited  attention,  and  led  to  farther  attempts  to  neat 
congenital  displacements  of  the  femur,  which  in  some 
instances,  as  verified  by  scientific  authority,  were  attended 
with  success. 

Another  surgeon  of  some  eminence.  M.  Bouvier,  pi 
Paris,  has  also  made  attempts  to  reduce  these  dislocations, 
hut  failing  to  accomplish  this  object,  he  has  denied  the 
Utility  of  therapeutic  means  in  these  affections. 

The   successful   efforts,    however,    of    M    Pravaz,   oi 

15 


218  TREATMENT. 

Lyons,  in  the  treatment  of  congenital  dislocations  at  the 
ilio-femoral  articulation,  authenticated  as  they  have  been 
by  positive  testimony,  place  beyond  a  doubt  the  practi- 
cability of  reducing,  under  favorable  circumstances,  the 
head  of  the  femur  to  its  natural  receptacle,  and  the  possi- 
bility of  retaining  it  there  permanently. 

The  utility  of  remedial  means  being  doubted,  and  the 
curability  of  this  dislocation  being  still  denied  by  some 
men  well  instructed  in  the  profession,  the  Royal  Academy 
of  Medicine  of  Paris,  in  1838.  appointed  a  commission  to 
report  upon  a  case  presented  by  M.  Pravaz,  as  establish- 
ing the  possibility  of  reducing  permanently  the  congenital 
dislocation  of  the  head  of  the  femur  upon  the  ilium. 

The  subject  of  this  critical  examination  was  a  male 
child,  seven  years  of  age,  affected  with  congenital  luxa- 
tion of  the  right  femur  upon  the  external  surface  of  the 
ilium.  The  diagnosis  had  been  confirmed  by  an  eminent 
surgeon,  M.  Richard,  of  Nancy — the  treatment  was  com- 
menced in  March,  1836 — and  the  commission  of  the 
Royal  Academy  of  Medicine,  composed  of  MM.  Blandin, 
Gerdy,  Sanson,  and  Naquart,  reported  on  the  case  in 
1838.  They  commenced  their  statement  by  admitting 
that  the  child  had  been  affected  with  congenital  disloca- 
tion on  the  ilium,  and  close  their  extended  report — drawn 
up  by  M.  Gerdy — as  follows : — "  D'apres  tout  cela, 
Messieurs,  est-il  possible  de  contester  le  succes  obtenu  par 
M.  Pravaz  1     Nous  ne  le  pensons  pas,  au  moins  quant  au 


THE  I  i  MEN  i  .  2]  9 

jeune  garcon  dont  nous  venons  de  vous  entretenir;  et 
pour  o'assurer  que  ce  que  qous  avons  \u  par  Qous-memes, 
nous  affirtnons  que  ce  jeune  malade  n'esl  point  affecte* 
aujourd'bui  de  luxation  cong6nitale.w* 

Without  mentioning  other  cases  to  the  9ame  effect, 
brought  forward  in  addition  by  M.  Pravaz,  and  confirmed 
by  names  eminent  in  science,  I  think  the  above  case, 
reported  upon  by  the  commission  of  the  Royal  V.cadetnj 
of  Medicine  of  Paris,  and  asserted  subsequently  as  re- 
maining cured,  two  years  after  the  reduction,  sufficient  to 
establish  the  principle  of  the  curability,  under  favorable 
circumstances,  of  congenital  luxation  of  the  femur  upon 
the  ilium. 

Still  more  recently,  additional  resources  have  been  used 
by  M.  Guerin,  in  the  treatment  of  these  displacements. 
Tn  those  instances  where  the  head  of  the  femur  has  been 
reduced,  and  where,  from  the  continued  muscular  retrac- 
tion, and  the  defective  formation  of  the  acetabulum,  i;  has 

been  found  impossible  to  retain  the  bead  of  tie-  lemur  in 
its  normal  position,  M.  Guerin  has  advised  the  division  of 
die  retracted  muscles,  and  has  also  practised  subcutaneous 
scarifications  in  the  \i<init\  of  the  cotyloid  cavity,  in 
order  to  provoke  an  effusion  of  organizing  material,  bj 
which  the  defect  in  the  acetabulum  ma\  lie  remedied,  and 
the  head  of  the  femur  thus  be  retained  in  its  cavity,  and 
supplied  with  a  sufficient  'point  >Fu/>>>'//. 

•  Traiii- '1.-  Luxations  Congenitales  du  1't'mur.  pai  le  Docteui  Prevail  1841 


220  TREATMENT. 

In  1843,  the  Council  General  of  the  Civil  Hospitals 
of  Paris  nominated  a  commission  to  inspect  the  treatment 
advocated  and  practised  by  M.  Guerin,  at  the  Hopital 
des  Enfans,  in  relation  to  congenital  dislocations  of  the 
femur,  and  to  other  deformities.  The  commission  was 
composed  of  MM.  Rayer,  Serres,  Louis,  Jobert,  Blandin, 
and  Orfila.  In  their  report  upon  three  cases  of  congeni- 
tal dislocation  of  the  femur  upon  the  ilium,  which  they 
had  observed,  they  thus  conclude  their  report  on  the 
peculiar  treatment  adopted  by  M.  Guerin  : — "  Quant  a 
l'efficacite  des  methodes  de  traitement,  nul  doute  que  les 
resultats  obtenus,  rapproches  surtout  de  ceux  qui  existaient 
deja  dans  la  science,  ne  temoignent  de  la  maniere  la  plus 
positive  en  faveur  de  ces  methodes.  II  est  a  remarquer  d'ail- 
leurs  que  les  ameliorations  d'un  genre  tout  particulier,  et  con- 
sistant  dans  un  ordre  de  faits  entierement  nouveaux,  obtenus 
dans  les  deux  premiers  cas,  ouvrent  a  l'art  des  ressources 
sur  lesquelles  il  n'avait  pas  compte  jusqu'ici."*  Thus 
we  see  that  congenital  dislocations  of  the  head  of  the 
femur,  long  considered  beyond  the  reach  of  surgical  aid — 
like  other  maladies  of  a  kindred  character,  regarded  at 
one  time  in  the  same  light,  such  as  Talipes,  Strabismus, 
&c,  though  not  equally  complicated — have  yielded  to 
therapeutic  resources,  derived  from  the  increased  know- 
ledge which  pathology  and  physiology  have  afforded. 

Let  it  not  be  supposed,  however,  that  in  admitting  the 

*  "  Rapport  de  la  Commission,"  &.c,  1846. 


TEE  \tmi:nt. 

curability  of  these  connate  displacements  of  the  hip-joint, 
I  overlook,  the  serious  nature  of  this  affection,  and  the 
difficulties  to  be  encountered  in  effecting  a  permanent  ad- 
justment of  the  articulation. 

As  the  treatment  is  not  immediately  effective,  as  in  the 
traumatic  dislocations  of  this  joint,  bul  aecessarilj  pro- 
longed and  tedious,  it  may  he  a  question,  whether  the 
advantages  derived  from  a  successful  result  would  com- 
pensate for  the  delay  and  difficulty,  by  which  onlj  it  could 
be  obtained. 

When  the  gravity  of  this  affection  and  the  evils  it 
entails  upon  existence,  and  which  go  on  increasing  as 
long  as  the  displacement  remains,  are  considered,  the 
importance  of  the  re-adjustment  of  the  articulation  can- 
not admit  of  a  doubt.  The  lameness  alone,  with  its 
inconveniences,  might  be  submitted  to,  but  as  a  result  <»t 
the  displacement,  nearly  one  half  of  the  organism  becomes 
perverted  in  its  structure  and  functions,  on  account  ol  the 
deterioration  of  the  several  tissues,  extending  even  to  the 
osseous.  The  pelvic  diameters  also,  in  the  female,  become 
so  changed  as  to  render  parturition  dangerous  or  impos- 
sible. 

The  treatment  of  congenital  dislocations  of  the  femoi 
ought  to  commence  as  soon  after  the  discover}  ol  the  dis- 
placement as  the  tractabilitj  of  the  patient  may  render 
practicable.  Imong  the  cases  of  success  mentioned,  the 
ages  have  been,  from   as  earl)  as  three,  to  six,  eight,  and 


222  TREATMENT. 

twelve  years ;  although  an  instance  of  successful  reduction 
at  the  age  of  fifteen  is  recorded.  The  capsule  at  these 
early  periods,  although  contracted  at  its  centre,  may  yet 
be  entire  in  its  structure ;  the  round  ligament  with  its 
vessels,  may  be  only  elongated  and  stretched,  but  not  yet 
ruptured  or  worn  through  ;  and  the  head  of  the  femur 
and  acetabulum,  although  somewhat  modified  in  shape, 
from  the  disturbance  of  their  normal  relations,  are  still 
susceptible  of  being  again  brought  into  a  state  of  recipro- 
cal adjustment  with  comparative  facility. 

In  connexion  with  these  data  afforded  by  the  patholo- 
gical conditions  at  the  early  period  of  this  displacement — 
even  where  the  acetabulum  has  become  considerably 
changed  in  shape — the  physiological  principles,  from  which 
therapeutic  means  have  been  adopted,  are  expressed  in  the 
proposition,  "that  we  may,  by  continued  and  progressive 
mechanical  action,  sometimes  restore  the  head  of  the 
femur  to  the  rudimentary  cotyloid  cavity,  whence  it  had 
been  dislodged  before  birth,  and  maintain  it  in  this  place 
of  election,  where,  by  the  plastic  effort  of  the  organism,* 
assisted  by  suitable  movements,  in  imitation  of  those  of 
ambulation,  the  head  will,  at  last,  form  for  itself  a  kind  of 
artificial  articulation. "f 


*  This  term,  denoting  the  reparatory  process,  is  synonymous  with  the  nisnt 
formatitus  of  Blumenbach,  and  the  organic  force  of  Miiller  ;  for  ?ome  interesting 
rem  ;.k-  on  which  see  Paget's  Lectures,  in  the  London  Medical  Gazette. 

t  Pravaz. 


TRB  I  I  mi.m  . 

If  oihcr  favorable  conditions,  such  as  the  general  good 
health,  besides  the  youth  of  the  patient  ;  the  absence  <<i  a 
false  articulation  upon  the  dorsum  ilii  ;  the  continuant 
and  free  movement,  of  the  bead  <>f  the  femur  within  the 
capsular  ligament,  accompany  the  case;  the  application  «>t 
remedial  measures  ma)  be  commenced  with  a  prospect 
of  ultimate  success. 

The  curative  treatment  of  congenital  dislocation  of  the 
head  of  the  femur  upon  the  ilium  comprises  three  periods, 
viz.,  first,  the  preparatory  extension;  secondly,  tin-  redac- 
tion ;  thirdly,  the  normal  consolidation  of  the  articular 
structures,  so  that  the  head  of  the  femur  may  be  perma- 
nently retained  in  the  acetabulum. 

The  different  kinds  of  apparatus,  which  have  been  con- 
trived to  fulfil  these  indications,  are  complicated  in  struc- 
ture, and  cannot  readily  he  understood  from  mere  verbal 
description;  I  have  therefore  introduced  drawings  of 
them,  from  the  designs  in  M.  Pravaz'  work,  that  the 
principles  of  treatment  may  he  better   comprehended.* 

The  method  of  effecting  the  preparatory  extension, 
and  the  apparatus  used  for  the  purpose,  is  represented  on 
Plate  A,  and  the  component  parts  of  it  are  explained  in 
the  accompanying  references.     It  will  be  seen,  03  turning 


»  I  have  in  tlii-  chapter  only  attempted  t>>  lay  down  tl 
treatment;  for  details  of  oases,  ill"  n  '-<1  to  the   I 

already  named. 


224  TREATMENT. 

to  the  plate,  that  the  patient  is  placed  in  the  recumbent 
posture  on  a  gently  inclined  plane.  The  limb  is  placed 
wirhin  a  padded,  thick  leather  encasement,  in  which  it  is 
secured  by  means  of  straps  and  buckles;  and  elastic 
extension  is  kept  up  by  a  weight,  attached  to  the  end  of 
a  cord,  which  passes  over  a  pulley  at  the  lower  part  of 
the  apparatus,  and  the  other  end  of  which  is  attached  to 
a  hook,  fastened  upon  the  lower  margin  of  the  leg-case. 
The  framework  of  the  apparatus  is  movable,  and  the 
cords  which  the  patient  is  seen  to  grasp,  can  impart 
various  motions  to  it,  by  being  pulled  upon ;  and  thus 
muscular  exercise  may  be  taken  during  the  treatment, 
without  interrupting  the  process  of  extension.  The 
counter-extension  is  maintained  by  the  thigh-strap,  aided 
somewhat  by  the  resistance  which  is  afforded  at  the 
axillae  by  the  crutch-like  supports.  The  patient  is  sub- 
mitted to  this  kind  of  extension,  which  at  first  ought  to 
be  gentle,  not  exceeding  at  the  outset  a  force  of  a  few 
pounds,  and  should  be  progressively  increased.  The 
duration  of  this  extension  may  vary  from  two  to  six 
months,  in  proportion  to  the  resistance  of  the  retracted 
muscles  and  ligaments. 

As  a  part  of  the  medical  treatment,  during  the  confine- 
ment necessarily  accompanying  the  period  of  preparatory 
extension,  the  use  of  the  condensed  air-bath,  at  a  pressure 
of  from  twelve  to  fifteen  centimetres,  has  been  recom- 
mended, especially   for  very  young  patients,  in   order  to 


TREATMENT. 

equalize  the  circulation,  and  counteract   the  evil  eflei  I 
the  confinement 

When  the  preparatory  extension  lias  been  maintained 
a  sufficient  length  of  time  i<>  effeci  the  descent  of  the 
head  of  the  femur  a  lit r  1< *  below  the  anterior  and  interior 
spinous  process  of  the  ilium,  and  the  projection  of  the  tro- 
chanter major  has  become  less  prominent,  and  the  incurva- 
tion of  the  lumbar  region  diminished,  reduction  ma\  then 
be  attempted. 

To  effect  reduction,  gentle  extension  must  be  kept  up, 
while  at  the  same  time  the  limb  is  abducted,  and  the  head 
of  the  femur  is  pushed  from  above  downwards,  and  from 
without  inwards.  One  method  of  accomplishing  this, 
will  be  understood  by  referring  to  Plate  B.  The  cord 
of  extension  is  here  removed  from  the  crotchet  attached 
to  the  inferior  part  of  the  leg-case,  and,  in  its  place,  a  set 
of  pulleys  is  affixed.  The  other  part  of  the  same  tackle 
is  attached  to  the  inferior  extremity  of  an  iron  lever, 
which  again  is  engaged  upon  a  vertical  pivot,  at  its  upper 
extremity,  so  as  to  be  movable  in  various  directions. 
This  vertical  pivot,  nivinu  the  point  (Toppui  to  the  lever, 
is  attached  to  the  side  of  the  apparatus  of  snstentation,  a 

little  below  and    to    the    outer    side    of  the    affected    joint. 

After  ibis  arrangement  is  completed,  the  assistant  is 
directed  to  exercise  gentle  traction  upon  the  cord  passing 
from  the   pulleys,  while   the   operator  himself  "pressing 

with  one  hand  on  the  trochanter,  from    above  downward*. 


226  TREATMENT. 

and  from  without  inwards,  directs,  with  the  other,  the 
lateral  movement  of  the  lever,  which,  turning  upon  its  pivot, 
will  carry  outwards  the  member  in  powerful  abduction." 

According  to  the  extent  of  the  malformation  which 
may  exist  at  the  acetabulum,  the  reduction  is  effected, 
either  immediately,  and  is  rendered  evident  by  the 
improved  conformation  at  the  joint,  sometimes  at- 
tended by  an  audible  sound,  as  happens  in  traumatic 
dislocations ;  or,  the  head  of  the  femur  can  only  be 
brought  into  its  anatomical  position  and  retained  there, 
until  the  plastic  power  of  the  organism  be  aroused,  and 
the  elemental  parts  of  the  joint  be  gradually  and  mutually 
adapted  to  each  other. 

To  prevent  the  re-escape  of  the  head  of  the  femur 
from  the  rudimental  cotyloid  cavity,  a  circumstance  which 
is  apt  to  occur,  two  large  concave  plates,  padded  and 
movable  upon  hinges,  are  fixed  upon  the  side  of  the 
apparatus,  as  seen  in  Plate  B,  and  which,  by  means  of 
screws,  may  be  so  adjusted  as  to  embrace  firmly  the 
haunches,  and  thus  retain  the  head  of  the  femur  in  its 
new  position. 

When  it  is  necessary  to  remove  the  patient  from  the 
bed,  a  girdle,  with  perineal  straps,  and  confining  the  hips, 
is  substituted,  to  prevent  the  femur  from  slipping  from  the 
acetabulum. 

A  short  time  after  the  reduction  has  been  effected,  pains, 
accompanied   by  heat  and  tumefaction,  are  manifested  in 


THE  ITMENT. 

the  inguinal  region,  attended  l>\  febrile  symptoms,  and 
sometimes  bj  dysurj  and  incontinence  of  urine,  [f  th 
symptoms  are  excessive,  1 1 1 » •  \  are  to  be  calmed  bj  a 
moderate  extension  of  the  affected  limb,  and  b\  emollient 
applications;  but  as  these  phlogistic  evidences  are  indi- 
cative of  the  occurrence  of  the  organo-plastic  effort,  upon 
which  the  remodelling,  as  it  were,  of  the  acetabulum, — as 
well  as  the  modifications  of*  the  adjacent  parts,  necessan 
for  the  maintenance  of  the  head  of  the  lemur  in  its 
new  position, — are  dependant,  they  are  to  be  regarded, 
when  not  excessive,  as  favorable  signs;  and  where 
too  feebly  developed,  they  must  be  aroused  by  artificial 
means. 

When  the  acetabulum  and  the  head  of  the  femur  are 
considerably  changed,  the  process  of  this  plastic  effort  of 
reparation  generally  requires  from  five  to  six  months, 
before  the  configuration  of  the  head  of  the  femur  and 
the  capacity  of  the  acetabulum  become  reciprocally  fitted 
for  each  other. 

In  cases  where  the  head  of  the  femur  is  at  first  placed 
upon  the  orifice,  as  it  were,  of  the  cotyloid  cavity,  during 
this  process  of  reparaion  CO-aptation,  the  head  of  tin 
femur  is  felt  to  pass  progressive!)  deeper  into  the  aceta- 
bulum, until  finally  the  more  perfect  adjustment  is  accom- 
plished. 

The  muscles  and  other  tissues,  being  now  placed 
in    more    normal    relations,    commence    to    assume 


2'28  TREATMENT. 

natural  disposition,  and  a  more  healthy  structural  appear- 
ance. 

When  the  articular  apparatus  of  the  joint  has  appa- 
rently become  adjusted,  and  the  head  of  the  femur  is  felt 
to  project  but  little  below  the  horizontal  branch  of  the 
pubes,  and  does  not  leave  the  articulation  during  the 
different  movements  of  the  limb,  especially  during  that  of 
adduction,  the  third  period  of  treatment  may  be  commenced. 

The  articulation,  being  still  fee  yet,  generally 

unable  to  support  the  superincumb  ^   t  of  the  trunk, 

without  a  recurrence  of  the  exarticulation  of  the  head  of 
the  femur. 

To  give  time  for  the  proper  consolidation  of  the  new 
relations  of  the  different  articular  structures,  at  the  same 
time  that  motion  and  exercise  shall  be  imparted  to  the 
joint,  while  the  weight  of  the  body  is  removed  ;  a  kind 
of  chair  has  been  made  use  of,  which  is  represented  on 
Plate  C  Upon  this  apparatus,  the  drawing  of  which 
is  sufficiently  explanatory  of  its  action,  the  patient  can 
lie  in  the  recumbent  posture,  and  by  means  of  its  me- 
chanism and  facility  of  movement  upon  wheels,  he  can, 
by  flexing  and  extending  the  limbs,  simulate  the  process 
of  ambulation,  and  throw  the  structures  of  the  joints  and 
surrounding  parts  into  exercise. 

This  kind  of  exercise  is  persevered  in  daily,  for  four 
or  five  months,  at  the  end  of  which  time  the  articulation 
has    generally    acquired    such    solidity    and    freedom    of 


TRKATMKVI 

motion,  that  the  bead  does  oot  become  exarticolated  even 
by  strong  adduction  of  the  limb.  When  these  conditions 
an-  present,  the  patient  is  then  allowed  to  take  exen 
in  the  ••reel  attitude,  l>ut  in  order  to  lessen  the  effeci  of 
the  superincumbent  weight  of  the  trunk  upon  the  articu- 
lation, the  apparatus,  represented  al  Plate  D,  is  resorted 
to;  a  reference  to  which  will  sufficiently  indicate  its 
mechanism  and  purpose. 

If,  as  son  ippens,   the   exercise  taken    in    the 

erect  posture  reproduce  the  dislocation,  recourse 

must  again  fck-  uati  to  the  use  of  the  apparatus  represented 
on  Plate  C;  and  it  may  even  be  necessary  to  provoke 
and  maintain,  by  artificial  pressure,  a  sufficient  degree  of 
irritation,  to  excite  anew  the  plastic  effusion  in  the  region 
of  the  joint. 

If,  however,  the  articulation  appears  to  have  acquired, 
by  these  various  means,  sufficient  strength,  alter  the 
continuance,  for  a  short  time,  of  the  kind  of  exercise  repre- 
sented on  Plate  D,  simple  crutches  are  then  resorted 
to,  for  a  while,  and  finally  the  patient  is  allowed  to  walk 
unaided  by  any  support. 

The  results  obtained  by  this  method  of  treating  these 
dislocations  have  proved  that  the  head  of  the  femur  can 
be  returned  to  its  natural  cavity,  ami  be  permanently  re- 
tained there:  and  although  a  slight  halt  in  the  gait  has 
geuer;ill\  remained.  \ci  the  lemurs  have  acquired  a  nor- 
mal point  ttappui  at   the  articulation  ;  and  the  inconve- 


230  TREATMENT. 

nicnces,  as  well  as  the  unseemly  deformity,  resulting  from 
the  displacement,  have  been  thus  evaded. 

The  softer  tissues  around  the  articulation  recover 
slowly,  but  the  return  to  their  natural  condition  may  be 
aided  by  muscular  exercise,  the  use  of  the  different  mineral 
baths,  friction,  electro-magnetism,  and  the  adoption  of  a 
measured  gait  in  walking. 

In  cases  where  the  dislocation  exists  upon  both  sides, 
the  difficulties  of  treatment  are  not  materially  increased, 
and  the  extension  may  be  resorted  tt>  upon  both  limbs 
at  the  same  time,  and  reduction  attempted  successively 
upon  each,  as  soon  as  the  position  of  the  head  of  the 
femur  and  the  elongation  of  the  soft  parts  may  warrant 
the  proceeding.* 

In  addition  to  the  preparatory  extension,  and  the  other 
means  mentioned  above,  which  have  been  employed  to 
effect,  and  render  permanent,  the  reduction  of  the  head  of 
the  femur  in  cases  of  congenital  dislocation  of  this  bone, 
M.  Guerin  has  offered  some  novel  suggestions  in  the 
treatment  of  this  affection      One  is,  to  practise  the  sub- 

*  I  have  not  alluded  to  the  palliative  treatment,  such  as  that  recommended  by 
Dupuytren,  of  wearing  a  girdle  around  the  haunches  to  embrace  the  pelvis,  and 
which,  by  grasping  the  trochanters,  is  intended  to  prevent  the  motions  of  the  exarti- 
culated  heads  of  the  femurs  along  the  dorsa  of  the  ilia  :  since  their  use  appears  to 
be  both  inconvenient  and  inefficient.  The  choice  of  an  occupati*  n,  however,  for 
persons  thus  affected,  and  who  from  their  age  are  beyond  remedy,  should  be  such  as 
not  to  keep  the  deranged  muscles,  as  the  psoas  magnus  and  iliacus  internus,  upon 
the   stretch  continually,  during  the  exercise  of  their  vocation. 


THE  \  i  mi.nt. 

cutaneous  section  ol  the  retracted  muscles,  thai  product  d 
the  dislocation,  generally    of  the  glutei      This  procedure 

is  resorted   to  alter  the   preparatorj  extension    has   ! 
kept  up  for  a  time,  and   has  been   found  unavailing  in 
maintaining  the  head   of  the  femur  opposite  the  aceta- 
bulum. 

In  those  cases  where  it  has  been  found  difficuh 
to  retain  the  head  of  the  femur  in  the  acetabulum, 
ow  ring  to  its  imperfect  formation  in  certain  points,  alter 
reduction  had  been  effected,  subcutaneous  scarifications 
around  the  acetabulum  have  been  recommended,  in 
order  to  induce  the  effusion  of  new  osseous   material,  to 

- 

remedy  the  defective  development  existing  upon   its  cir- 
cumference, 

The  other  suggestion  is,  to  make  a  subcutaneous  inci- 
sion into  the  capsule,  so  as  to  permit  the  head  of  the 
lemur  to  escape,  and  to  become  placed  in  direct  contact 
with  the  dorsum  of  the  ilium,  in  those  cases  where  reduc- 
tion cannot  he  accomplished  on  account  of  the  altered 
state  of  the  articulation,  and  where  the  head  of  the  bone 
continues  to  play  along  the  surface  of  the  external  iliac 
fossa.  This  proceeding  is  accompanied  l>\  additional 
scarifications  at  a  place  of  election,  in  the  vicinit\  ol  the 
acetabulum,  in  order  to  increase  the  irritation,  and  induce 
there  the  effusion  of  plastic  material  towards  the  forma- 
tion of  a  new  socket.  The  principle  upon  which  this 
treatment  is   founded  rests  upon    the  supposition,  thai    the 


232  TREATMENT. 

immediate  contact  of  the  two  osseous  surfaces  of  the 
head  of  the  femur  and  of  the  ilium,  will  induce  the  forma- 
tion of  a  new  acetabulum  upon  the  dorsum  of  the  ilium, 
as  takes  place  generally  in  cases  of  unreduced  traumatic 
dislocation  of  the  hip-joint  in  this  direction.  It  is  antici- 
pated here  that  a  new  socket  will  be  formed  for  the  head 
of  the  femur,  and  that  it  will  consequently  become  more 
fixed,  and  will  be  prevented  from  playing  upon  the 
external  surface  of  the  ilium,  during  progression. 

The  idea  of  tracing  an  analogy  between  the  circum- 
stances attendant  upon  an  unreduced  traumatic  disloca- 
tion of  the  femur  upon  the  ilium,  and  the  congenital 
luxation  of  the  femur  in  this  direction,  where  the  head 
has  escaped  from  its  capsular  ligament,  and  has  become 
placed  upon  the  dorsum  of  the  ilium,  is  plausible  ;  but  the 
supposition  that  the  formation  of  a  new  socket  always 
follows  the  escape  of  the  head  of  the  femur  from  the 
capsule,  whether  occurring  spontaneously  or  artificially,  is 
not  correct,  as  is  seen  from  the  description  of  the  patho- 
logical appearances  in  one  of  the  cases  of  this  displacement, 
previously  given,  and  exhibited  at  Plate  vii. 

The  theory  upon  which  this  treatment  is  predicated  is 
ingenious,  but  facts  do  not  corroborate  the  notions  upon 
which  it  is  founded.  Nevertheless,  it  is  not  improbable 
that  the  direct  apposition  of  the  osseous  tissues  of  the 
femur  aud  of  the  ilium,  after  the  escape  of  the  head  of 
the  femur   from   its  capsule,  may  predispose  to  the  forma- 


TREATMENT. 

Hon  of  ;i  vicarious  socket.  It  is  well  known  that  the 
effusion  of  osseous  material  is  invited  sometimes  l>\  irri- 
tation, as  i^  observed  in  Physick's  method  of  treating  dis- 
united fractures  by  the  insertion  of  the  setbn. 

In  practical  surgery,  every  reasonable  conjecture  merits 
consideration  ;  particularly  in  the  treatment  of  an  affec- 
tion so  formidable  as  congenital  dislocation  of  the  head  of 
the  femur  up(  n. 

The  subcut  ;tion  of  the  retracted  muscles  v 

at  times  be  ad. .. ,  eta  one  of  the  resources  of  art,  to  faci- 
litate reduction,  as  well  as  the  peri-articular  scarifications, 
to  aid  in  maintaining  reduction  after  it  has  been  effected. 
The  subcutaneous  incisions  of  the  capsular  ligament, 
with  scarifications  practised  at  the  same  time,  at  a  place 
of  election,  on  the  external  surface  of  the  ilium,  ma\ 
likewise  be  made  available,  in  those  cases  where  the 
brad  of  the  hour  cannot  otherwise  be  solidly  fixed,  nor 
prevented  from  playing  along  the  dorsum  of  the  ilium 
during  progression. 

Before  closing  these  remarks,  I  shall  offer  a  fevt  obser- 
vations on  congenital  sub-luxations  and  pseudo-luxations 
of  the   head  of  the  lemur. 

Although,  as  heretofore  stated,  the  partial  removal  of  the 
head  of  the  femur  from*  the  cotyloid  cavity,  termed  Conge- 
nital Si  B    Ll  KATION   OF  THE    lli:\l>   OF    I'HB    FeMI  R,  ma\ 

be  regarded  as  the  commencement  of  the  absolute  luxa- 
tion of  the  femur  upon  the  ilium,  yet  it  ma\  be  proper  to 

L6 


234  TREATMENT. 

observe  that  the  head  of  the  femur  may  remain  for  many 
years  in  this  initiatory  stage  of  displacement,  thus  in 
reality  constituting  a  variety  of  the  deformities  of  the  hip- 
joint. 

The  head  of  the  femur  is  here  found  resting  upon  the 
posterior  and  upper  part  of  the  margin  of  the  acetabu- 
lum, and  has  only  partially  escaped  from  its  cavity.  This 
variety  is  found  to  exist  at  birth,  and  it  also  may  take 
place  soon  after  birth,  from  muscular  retraction. 

The  diagnosis  in  instances  of  this  kind  must  be  care- 
fully formed,  by  attentive  examination,  and  from  the  facts 
heretofore  laid  down  in  the  chapters  on  the  Symptoma- 
tology and  on  the  Diagnosis.  The  treatment  must  be 
regulated  upon  the  general  principles,  already  recom- 
mended, in  relation  to  the  complete  congenital  dislocations 
of  the  head  of  the  femur. 

With  regard  to  the  Congenital  Pseudo-Luxations  of 
the  hip-joint,  as  they  are  called,  from  the  similarity  they 
bear  to  perfect  luxations  of  the  head  of  the  femur,  two  va- 
rieties have  already  been  spoken  of,  viz.,  one,  simulating  a 
luxation  of  the  head  of  the  femur  downwards  and  for- 
wards ;  the  other,  simulating  the  luxation  backwards  and 
upwards. 

The  latter  deformity  only,  can  be  mistaken  for  the  con- 
genital dislocation  of  the  femur  upon  the  ilium. 

In  these  deceptive  deformities,  which  are  also  caused  by 
muscular  retraction,  the  head  of  the  femur  still  remains  in 


TREATMENT. 

the  acetabulum,  and  thej  musi  be  distinguished  from 
those  cases  where  the  bead  of  the  femur  is  exarticulated, 
!)\  careful  manual  examination,  and  the  application  of  the 
diagnostic  symptoms,  already  pointed  our,  when  this  divi- 
sion of  the  subject  was  under  consideration. 

The  head  of  the  femur  in  these  instances  can  generally 
be  felt  in  the  fold  of  the  groin,  a  little  to  the  outer 
side    of    the  artery,    during    rotation     of    the 

limb;    and   t  ed    movements,  and  the  permanent 

deviation  of  the  members  from  their  natural  direction,  can 
generally  be  traced  to  a  retracted  condition  of  the  tensor 
vaginas  femoris  and  some  of  the  other  pelvi-femoraJ  mus- 
cles in  the  vicinity  of  the  joint. 

The  subcutaneous  section  of  the  retracted  muscles, 
aided  by  the  mechanical  means  applied  on  the  principles 
usually  observed  in  orthosomatic  therapeutics,  will  often 
remedy  these  deformities,  and  restore  the  functions  of  the 
affected  members  to  their  natural  condition. 


ERRATA 


Page  24,  line  18,  close  the  paragraph  at  "  upwards.'*  Then  read  as  a  new  para- 
graph :  "  A  sub-luxation  backwards  and  upwards  is  also  met 
with  ;   and.  lastly,  the  term  pseudo-luxation."  &c. 

"     56,     "     10,  tor  "hydrarthus"  read  "  hydrarthrus." 

"     79,     "       2,  for  '-column'"   read  •■  cord." 

"     95,     "     11,  for  "  excurvation "  read  "incurvation.'' 


jL2Af 


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